mental health researches

ISSN 1025 - 3823 Volume XII Number 3-4 2005 REVISTA INTERNACIONAL DE PROMOCIÓN DE LA SALUD Y EDUCACIÓN PARA LA SALUD INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION REVUE INTERNATIONALE DE PROMOTION DE LA SANTÉ ET D’ÉDUCATION POUR LA SANTÉ QUARTERLY TRIMESTRIEL TRIMESTRAL Published by the International Union for Health Promotion and Education. Promotion & Education: français page 182 español página 203 Global school health promotion Promotion & Education, the International Journal of Health Promotion & Education, is an official publication of the International Union for Health Promotion & Education (IUHPE). It is a multilingual journal, which publishes authoritative peer-reviewed articles and practical information for a world-wide audience of professionals interested in health promotion and health education. The content of the journal reflects three strategic priorities of the IUHPE, namely, advancing knowledge, advocacy and networking. Promotion & Education, la Revue internationale de Promotion de la Santé et d’Éducation pour la Santé, est une publication officielle de l’Union internationale de Promotion de la Santé et d’Éducation pour la Santé (UIPES). Il s’agit d’une revue multilingue, contenant des articles de référence sur tous les aspects théoriques et pratiques de la promotion de la santé et de l’éducation pour la santé. Elle s’adresse à un public de professionnels de toutes les régions du monde. Le contenu de la revue reflète trois des priorités stratégiques de l’UIPES, à savoir, développement des connaissances et compétences, plaidoyer pour la santé, et communication et travail en réseau. Promotion & Education, la Revista Internacional de Promoción de la Salud y Educación para la Salud es la publicación oficial de la Unión internacional de Promoción de la Salud y Educación para la Salud (UIPES). Es una revista que incorpora artículos revisados por una junta editora e incluye información práctica dirigida a una audiencia de profesionales interesados en los campos de la promoción de la salud y educación para la salud a nivel mundial. El contenido de la revista refleja las tres prioridades estratégicas de la UIPES, a saber, desarrollo de conocimientos y capacidades, argumentación en favor de la salud y fortalecimiento de los intercambios y del trabajo de redes. The views expressed in articles which appear in this journal are those of the authors, and do not necessarily reflect those of the IUHPE. Any material published in Promotion & Education may be reproduced or translated provided credit is given and copy sent to the address of the Journal. To order Promotion & Education in microfilm or microfiche, please contact: UMI Inc., 300 North Zeeb Road, P.O. Box 1346, Ann Arbor, Michigan 48106-1346, U.S.A. To advertise in Promotion & Education contact: IUHPE, 42 boulevard de la Libération, 93203 Saint-Denis Cedex, France. Tel: (33) 01 48 13 71 20. Fax: (33) 01 48 09 17 67. E-mail: cjones@iuhpe.org Les opinions exprimées dans les articles de cette Revue sont celles des auteurs et ne sont pas nécessairement celles de l’UIPES. Toute reproduction ou traduction des textes parus dans Promotion & Education est autorisée sous réserve de la mention de la source et de l’envoi d’ une copie à l’adresse de la Revue. Pour commander Promotion & Education sous forme de microfilm ou microfiche, veuillez contacter: UMI Inc., 300 North Zeeb Road, P.O. Box 1346, Ann Arbor, Michigan 48106-1346, U.S.A. Pour passer des publicités dans Promotion & Education, veuillez contacter l’UIPES, 42 boulevard de la Libération, 93203 Saint-Denis Cedex, France. Tel: (33) 01 48 13 71 20. Fax: (33) 01 48 09 17 67. E-mail: cjones@iuhpe.org Las visiones y opiniones expresadas en la revista por los autores de los artículos no reflejan necesariamente la visión institucional de la UIPES. Todo material publicado en la Revista Promotion & Education que sea reproducido o traducido deberá ofrecer crédito a la revista y deberá enviarse copia a la dirección de la revista. Para ordenar Promotion & Education en forma de microfilm o microficha, contactar : UMI Inc., 300 North Zeeb Road, P.O. Box 1346, Ann Arbor, Michigan 48106-1346, U.S.A. Para publicar un anuncio en Promotion & Education, contactar la UIPES, 42 boulevard de la Libération, 93203 Saint-Denis Cedex, France. Tel: (33) 01 48 13 71 20. Fax: (33) 01 48 09 17 67. E-mail: cjones@iuhpe.org Subscription The journal is published four times a year, with an index of articles included every two years. All members of the IUHPE automatically receive Promotion & Education. It is also available by subscription. For readers in Europe, North America, Northern Part of Western Pacific, South West Pacific: Ind. 71 €, Inst. 104 €. For readers in Africa, Eastern Mediterranean, South-East Asia, Latin America: Ind. 37 €, Inst. 42 €. Individual copies of current and back issues may be ordered for 16 €. To subscribe to Promotion & Education, write to: Abonnement La revue est publiée quatre fois par an, avec un index des articles tous les deux ans. Tous les membres de l’UIPES recoivent automatiquement la revue Promotion & Education, et elle est aussi disponible par abonnement. En Europe, Amérique du Nord, Pacifique Occidental Nord, et Pacifique Occidental Sud : Ind. 71 €, Inst. 104 €. En Afrique, Méditerranée Orientale, Asie du Sud-Est, et Amérique Latine : Ind. 37 €, Inst. 42 €. Il est possible de commander des numéros individuels de la revue : 16 € par numéro. Pour s’abonner à Promotion & Education, veuillez contacter : Suscripción La revista se publica cuatro veces al año. Cada dos años se incluye un índice de los artículos publicados. Todos los integrantes activos de la UIPES reciben una copia de la revista como beneficio de su membrecía a la organización. La revista también está disponible mediante suscripción. Para los lectores de Europa, Norteamérica, Pacífico occidental norte y Pacífico occidental sur, el precio de la revista es : Ind. 71 €, Inst. 104 €. Para los lectores de Africa, países del Mediterráneo oriental, del Sureste de Asia y de América Latina, el precio de la revista es : Ind. 37 €, Inst. 42 €. Es posible solicitar copias individuales de los números actuales y anteriores a precio de 16 € . Para suscribirse a Promotion & Education, contactar : IUHPE/UIPES – 42, boulevard de la Libération 93203 Saint-Denis Cedex – France. Tel: 33 (0)1 48 13 71 20 Fax: 33 (0)1 48 09 17 67 E-mail: jcadinu@iuhpe.org www.iuhpe.org Founding Editor – Fondatrice – Fundadora: Annette Kaplun • Director – Directeur: Pierre Arwidson • Editorial Advisory Board –Conseil de Rédaction – Consejo Editorial: Hiram Arroyo (Puerto Rico), Dora Cardaci (Mexico), Juan-Manuel Castro (Mexico), Alain Deccache (Belgium), Atsuhisa Eguchi (Japan), Shane Hearn (Australia), Saroj Jha (India), Lloyd Kolbe (USA), Balachandra Kurup (India), Diane Levin (Israel), Gordon MacDonald (United Kingdom), David McQueen (USA), Maurice Mittelmark (Norway), David Nyamwaya (Kenya), Michel O’Neill (Canada), K.A. Pisharoti (India), Mihi Ratima (New Zealand), Irving Rootman (Canada), Becky Smith (USA), Jim Sorenson (USA), Alyson Taub (USA), Thomas Karunan Thamby (India), Keith Tones (United Kingdom), Marilyn Wise (Australia), Pat Youri (Kenya) • Executive Editorial Board – Comité de Rédaction – Comité Editorial : Editor in Chief - Rédactrice en Chef - Jefa de redacción : Jackie Green • Managing Editor - Coordinatrice éditoriale - Coordinadora editorial : Catherine Jones • Assistant - Assistante - Asistente: Martha Perry • Ex-officio: Marie-Claude Lamarre • Translators – Traducteurs – Traductores: Ma. Asunción Oses, Martha Perry, Marie-Cécile Wouters • Graphic Design – Conception Graphique – Diseño gráfico: Frédéric Vion (01 40 12 27 41) • Printer – Imprimeur – Impresor: Imprimerie Landais – 93160 Noisy- le-Grand (01 48 15 55 01) Commission paritaire n° AS 64681 du 14-09-8 • With the assistance of – Collaboration – Con la colaboración de: Veronika Farkas, Lilla Vetõ, Antonio Sáez, Réal Morin, Johanna Laverdure • Peer reviewers 2005- Reviseurs 2005- Revisores 2005: Anne Bunde-Birouste, Dora Cardaci, William Chen, John Kenneth Davies, Donald Fedder, Nick Gilson, Deborah Glik, Sarah Gordon, Spencer Hagard, Steve Hawks, Sung Hee Yun, Su-I Hou Suzanne Jackson, Dawn Johnston, Bill Kane, Chuck Kozel, Ronald Labonte, Albert Lee, Diane Levin, Gordon MacDonald, Bruce Maycock, Maurice Mittelmark, Naomi Modeste, Eun-Woo Nam, Vivian Rasmussen, Irving Rootman, Francisco Soto Mas, Alyson Taub, Keith Tones, Isabelle Vincent. English Section Preface 109 Promoting school health around the world through the CDC and IUHPE Cooperative Agreement M. Perry Editorial 111 Health promotion in schools– a historical perspective I. Young Advancing Knowledge 118 What do we know about promoting mental health through schools? K. Weare and W. Markham 123 Evaluating health promotion in schools: a case study of design, implementation and results from the Hong Kong Healthy Schools Award Scheme A. Lee, L. St Leger and A. Moon 131 Successful strategies and lessons learned from development of large-scale partnerships of national non-governmental organisations W. Potts-Datema et al. Case Studies 130 • A systems approach to health promoting schools C. M. Stanton 138 • A health promoting school approach used to reduce the risks of lead poisoning and to establish cross-ethnic collaboration A. Tahirukaj, I. Young and G. McWeeney 140 • Look after the staff first– a case study of developing staff health and well-being J. Mason and L. Rowling 142 • Empowering children for risk taking– children’s participation as a health promoting strategy in the “Safe Schools in a Community at Risk” project L. Kostarova Unkovska 144 • Health promotion practices in Chinese urban schools M. Thomas and W. Weng Advocacy 145 Protocols and Guidelines for Health Promoting Schools L. St Leger 150 Involving students in learning and health promotion processes– clarifying why? what? and how? B. B. Jensen and V. Simovska 157 Health programmes for school employees: improving quality of life, health and productivity L. J. Kolbe et al. 162 Challenges in teacher preparation for school health education and promotion B. J. Smith, W. Potts-Datema and A. E. Nolte Case Studies 148 • Children as health promoters B. B. Mukhopadhyay and P. C. Bhatnagar 165 • Problem Solving for Better Health (PSBH) and health promoting schools: participatory planning and local action in the Rio de Janeiro programme D. Becker et al. 166 • Improving community hygiene and sanitation practices through schools: a case study of the Personal Hygiene and Sanitation Education (PHASE) project in Kenya D. K. Wamalwa Networking 168 What is a network? What makes a health promoting schools network? D. H. Rivett 169 The European Network of Health Promoting Schools – from Iceland to Kyrgyzstan V. Barnekow Rasmussen 173 The International School Health Network: an informal network for advocacy and knowledge exchange. D. S. McCall, I. Rootman and D. Bayley 180 Abstract Case Studies 178 • Mainstreaming health promotion in education policies: a Uruguayan experience S. Meresman 179 • Promoting health in French schools S. Broussouloux and N. Houzelle Contents Sommaire Índice Volume XII Number 3-4 2005 “My school”. Latvian pupils concept of a healthy school. Zentenes primary school, Latvia. Dossier Français Preface 182 Promouvoir la santé en milieu scolaire à travers le monde dans le cadre de l’Accord de Coopération entre les CDC et l’UIPES M. Perry Éditorial 184 La promotion de la santé à l’école –une perspective historique I. Young Développement des connaissances 191 Résumés Plaidoyer 193 Protocoles et Lignes directrices pour les Ecoles promotrices de Santé L. St Leger 195 Résumés Travail en réseau 198 Qu’est-ce qu’un réseau ? De quoi est fait un réseau d’écoles promotrices de santé ? D. H. Rivett 199 Résumés Étude de cas 201 • Promouvoir la santé dans les établissements scolaires français S. Broussouloux et N. Houzelle Cuaderno Español Prefacio 203 Promover la salud escolar en el mundo a través del Acuerdo de Cooperación entre los CDC y la UIPES M. Perry Editorial 205 La promoción de la salud en la escuela– una perspectiva histórica I. Young Desarrollo de conocimientos 212 Resúmenes Abogacía 214 Protocolos y Directrices para las Escuelas Promotoras de Salud L. St Leger 216 Resúmenes Trabajo en red 219 ¿Qué es una red? ¿Qué constituye una red de escuelas promotoras de salud? D. H. Rivett 220 Iniciativa Regional Escuelas Promotoras de la Salud en las Américas J. Ippolito-Shepherd, Ma. T. Cerqueira y D. P. Ortega 230 Resúmenes Estudios de caso 231 • Transversalizar la promoción de salud en las políticas educativas: la experiencia de Uruguay S. Meresman 232 • Promover la salud en las aulas escolares francesas S. Broussouloux y N. Houzelle Volume XII Number 3-4 2005 Contents Sommaire Índice The International Union for Health Promotion and Education (IUHPE) would like to kindly acknowledge the contribution of the NHS Health Scotland (a Trustee member of the IUHPE) in the preparation and realisation of this publication. The investment and valuable support in terms of both financial and human resources received from NHS Health Scotland for this special issue was instrumental in the successful completion of this publication. L’Union internationale de Promotion de la Santé et d’Éducation pour la Santé est très reconnaissante de la contribution apportée par le NHS Health Scotland (Membre administrateur de l’UIPES) à la préparation et à la réalisation de cette publication. Les ressources tant humaines que financières investies par le NHS Health Scotland dans ce numéro spécial ont été essentielles à l’accomplissement de ce projet en partenariat. La Unión Internacional de Promoción de la Salud y Educación para la Salud (UIPES) agradece la amable contribución de NHS Health Scotland (Servicio Nacional de Salud de Escocia), miembro administrador de la UIPES, en la preparación y realización de esta edición. La inversión financiera y dedicación humana por parte de NHS Health Scotland en este número ha sido imprescindible para su fructuosa publicación. preface 109 IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 “This special issue of Promotion & Education surely will become a landmark in the evolution of school health programmes, and should do much to improve our understanding and development of such programmes around the world.” Lloyd Kolbe, Professor of Health Education, University of Indiana, USA. The International Union for Health Promotion and Education (IUHPE) has been a leading organisation in creating the ground to bring together international experts around the subjects of child and adolescent health and school-based health promotion, and traces decades of relevant experience since its inception (Modolo & Mamon, 2001). The IUHPE has organised, on three occasions since 1987, special issues of its official Journal, Promotion & Education, devoted to effectiveness and quality in school health. In addition IUHPE has featured school health in an important review of effective school health promotion in the report entitled The Evidence of Health Promotion Effectiveness: Shaping Public Health in a new Europe, where the authors address the health, social, economic and political impact of health promotion in schools (IUHPE, 2000). In the area of knowledge exchange, the IUHPE’s World and Regional Conferences on Health Promotion and Health Education frequently feature the best practice in the promotion of health in schools. It was from these gatherings that the organisation’s present work in the area of school health emerged and flourished under the auspices of the IUHPE and the CDC partnership. Martha Perry Promoting school health around the world through the CDC and IUHPE Cooperative Agreement The IUHPE, as an independent, global non- government organisation, acts in the agreement as the facilitating and coordinating agency for comprehensive global health promotion and health education programmes at the global and regional levels. The work plans are designed to develop public health policies, build capacity and disseminate evidence-based knowledge and practical experience. In line with this overall objective, the two partnering agencies identified a number of common interest areas, among them, schools, with the aim to support activities which strengthen international, national and local efforts for effective school-based health promotion programmes. The school health programme element has developed, among its most pertinent activities, the Protocols and Guidelines for Health Promoting Schools (see page 145) under the leadership of Professor Lawrence St Leger, from the Faculty of Health and Behavioural Sciences at Deakin University, Australia. The production of this document is the result of on-going discussions with renowned professionals which began at the IUHPE’s 17 th World Conference in 2001 and continued in 2004 at the 18 th World Conference, where the participants recommended the production of a coherent document that could provide a blueprint for improving the evidence base for health promoting schools. Fundamental to this effort has been revisiting the five areas outlined in the Ottawa Charter for Health Promotion as they apply to school health promotion: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services (WHO, 1986; Wagner, 2002). To contribute to its content, input from professionals was solicited and research on the practice of international organisations, such as, WHO and CDC, has been collected. Evidence of effectiveness has proven to contribute to programme implementation and funding, and this document on evidence-based health promoting schools will serve as a cornerstone for policy makers and practitioners, not only in the field of school health, but also other health promotion settings that influence the health of students, teachers and communities as a whole. The document was launched during two workshops 109 109 Martha Perry IUHPE Project Assistant Email: mperry@iuhpe.org This themed issue of Promotion & Education has received financial support from the United States’ Centers for Disease Control and Prevention (CDC), an Agency of the Department of Health and Human Services, under the Cooperative Agreement Number U50/CCU021856 on Global Health Promotion and Health Education Initiatives. Its contents are solely the responsability of the authors and do not necessarily represent the official views of CDC. IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 110 held in October 2005 at the American School Health Association’s Annual Conference, where it was very well received and a number of significant recommendations were made. Dissemination avenues for this document include: the Global Programme on Health Promotion Effectiveness (GPHPE), coordinated by the IUHPE in collaboration with WHO, CDC and other institutional partners; the IUHPE 19 th World Conference on Health Promotion and Health Education in June 2007; as well as through various networks, such as, the informal International School Health Network (ISHN), the European Network of Health Promoting Schools (ENHPS) and the Latin American and Caribbean Networks of Health Promoting Schools. Furthermore, the 2004 conference underlined the importance of this area of work with a day-track focusing exclusively on health in schools. The gathering served to highlight the significant number of professionals working in school health promotion. It also revealed that there is room for improvement in sharing knowledge beyond national networks. As a result, the formation of an informal International School Health Network (ISHN) has emerged as a means to communicate information and encourage the use of comprehensive approaches to school-based health promotion/health promoting schools. More information on this network is provided in this issue’s article by Douglas McCall (page 173). The IUHPE has been an integral part of the discussions to develop a networking strategy and envisages to take a greater role in its coordination together with other leading international and national partners, such as WHO, UNICEF and CDC. To further advance knowledge and disseminate the work being done around the world, the production of this special issue came about. The leadership role in this task has been taken on by Ian Young, from NHS Health Scotland, working together with IUHPE’s editorial team and Lawrence St. Leger, as the counterpart principal collaborator of the school health programme in the cooperative agreement. The aim of this edition is to give a global portrait on the state of the art of school health which we believe will make the issue a defining point in the development of health promotion in schools. The approach is to push the thinking on school health promotion forward, not merely depict interventions on what works in different settings and for different populations, while achieving the widest global outreach possible. The value added of this compilation of papers is a genuine reflection on the value of specific approaches. School health has been an integral component of the IUHPE’s work and, in particular, in the Cooperative Agreement with CDC for the past four years. The five-year work plan under this collaborative effort will culminate in 2007, coinciding with the 19 th IUHPE World Conference on June 11-15 in Vancouver, Canada (www.iuhpeconference.org), making this conference the perfect setting to disseminate the work done. The IUHPE’s experience gained and quality network formed, in cooperation with CDC and key internationally renowned consultants, have been invaluable in planning and implementing the different activities. Some challenges will be overcome and other new ones will appear. Nevertheless, the IUHPE will continue to work with its partners in this area since evidence of effectiveness shows that, among others, when it comes to schools, health is as important as literacy and both constitute on-going and intertwined developments. As Modolo & Mamon (2001) pointed out: “We cannot afford to leave the health citizenship of the future to generations only casually educated about life.” References IUHPE (International Union for Health Promotion and Education) (2000). The Evidence of health promotion effectiveness: Shaping Public Health in a New Europe. A report for the European Commission. Paris: Jouve Composition & Impression: p. 110-122 Modolo, Ma. A. & Mamon, J. (2001). Children and Youth. In IUHPE (International Union for Health Promotion and Education) A Long Way to Health Promotion through IUHPE Conferences 1951- 2001. Perugia: University of Perugia, Interuniversity Experimental Center for Health Education: 123-125. Wagner, G. H. (2002). Health promoting schools evidence for effectiveness workshops report. Promotion & Education, IX (2): 55-61. World Health Organization (WHO) (1986). Ottawa Charter for Health Promotion. World Health Organization, Geneva, Switzerland. Ian Young, Scotland, page 114 on different language and concepts across sectors– ‘‘To many progressive educationalists a term such as health promotion is not considered necessary in relation to schools, because they may view the curriculum of a school as everything a school does and not merely the learning and teaching of the classroom.’’ Katherine Weare, England, page 119 on effectiveness in mental health promotion– ‘‘There have been several recent large scale systematic reviews of the research evidence, including evidence from controlled studies, which have concluded unequivocally that initiatives that use a range of contexts, opportunities, approaches and agencies are more effective than more limited and one dimensional approaches when attempting to tackle mental health.’’ Albert Lee, Hong Kong, pag 128 on school effectiveness– ‘‘Apart from addressing the complexity of health promotion initiatives, the evaluation of school health promotion also needs to address school improvement and effectiveness which can be useful and meaningful for both the education and health sectors.’’ William Potts-Datema, U.S.A., page 136 on partnership-working in advocacy– ‘‘Like any partnership, the ability to work and grow is dependent on the level of trust among the partners. Consciously working to build trust is the most significant internal work of these collaboratives.’’ Ardita Tahirukaj, Kosovo, page 139 on health promotion training and healing relationships between communities– ‘‘It is clear that the development of joint training in health promoting schools is one small but important way in which the two ethnic groups can work together to improve trust and relationships for the future.’’ Lina Kosterova Unkovska, Macedonia, page 142 on the resources young people have within– ‘‘Children in communities exposed to rapid changes such as a war or refugee crisis are forced to learn quickly - more quickly than children in more stable environments. Marginalized and deprived of their rights they will, counter to all expectations, demonstrate higher motivation and persistence.’’ Lawrence St Leger, Australia, page 145 On sustaining change– ‘‘Establishing a health promoting school is not a project. It is a process of change and development which builds a healthy school community.’’ Bhavna Mukhopadhyay, India, page 148 On children as the educators– ‘‘The school children, who are the first generation to be educated, became the agents of change. Their role was to promote healthy behaviours amongst younger children, children of same age, their immediate families and larger community.’’ Bjarne Bruun Jensen, Denmark, page 155 On student participation– ‘‘Inherent within the conceptualisation of teaching and learning through genuine participation are issues of power and ownership. Genuine student participation allows for student ownership of the learning process.’’ Becky Smith, U.S.A., page 164 on teacher education and training– ‘‘The relative isolation of some university faculty and programmes has developed an interesting situation in which many administrators and master teachers at the K-12 level of education have a better grasp and understanding of new teaching and learning strategies and tools than professors at the university level.’’ David Wamalwa, Kenya, page 166 on the positive outcomes of an experimental study– ‘‘An evaluation done in the year 2004 revealed that the project Personal Hygiene and Sanitation Education in Kenya had contributed to a significant reduction in school absenteeism and improvement in performance in national examinations.’’ Vivian Barnekow Rasmussen, page 169 on the ENHPS and its inter- sectoral approach– ‘‘There is an increasing recognition that new forms of partnership and inter-sectoral working are required if the social and economic determinants of health are to be addressed. Investments in both education and health are compromised unless a school is a healthy place in which to live, learn and work.’’ Douglas McCall, Canada, page 175 on the formation of a new global network– “…there is no mechanism that brings together all of the national officials, researchers and associations, the health and education sectors, as well as the networks concerned with health issues and those that work in school health promotion in various languages. That is the niche that the International School Health Network (ISHN) can fill.’’ Sergio Meresman, Uruguay, page 178 on integrating innovation within schools– ‘‘What makes health promotion sustainable in schools is integrating it with the existing policies aimed at improving teaching and learning and putting it in the hands of those that construct everyday life in the schools.’ Editor’s notes 111 IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 14 good reasons to read on – a snapshot from the editor’s wide-angled lens On page 51 Lloyd Kolbe suggests 14 good reasons why workplace health promotion programmes are effective and how this is relevant to school health. Below you will find 14 additional examples and quotations from across the world which explore the many dimensions of health in schools. These should stimulate your thinking and keep you informed of new developments in health promotion in schools. IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 112 ❚ Welcome to this special edition of Promotion & Education which focuses our wide angled lens on health promotion in schools. I was delighted and honoured to accept International Union for Health Promotion and Education’s (IUHPE) invitation to write this introductory paper and to act as guest editor for this special edition. It is an exciting time for health promotion in schools with the growth of international networks and a very high level of political and professional interest in the issues. This was clearly exemplified by the attendance figures for events within the schools theme at the 18 th IUHPE World Conference on health promotion and health education held in 2004 in Melbourne, Australia, and the interest being shown in school health as a theme at the next world conference in Vancouver from June 11 th to 15 th , 2007. In this paper I wish to look back briefly at the recent history of health promotion in schools. My own experience is predominantly in the European context and this immediately introduces an Ian Young Health promotion in schools – a historical perspective element of selection and a risk of bias, although I hope that with my international experience I have minimised the bias if not the selective nature of my memory! I will attempt to show that, despite differences in nomenclature in Europe and the United States, the fundamental conceptual development is convergent rather than divergent in nature. This editorial will also look forward and introduce to you the themes that our commissioned experts have developed further for your own consideration and reflection. The whole edition also aims to be a stimulus for more debate and networking and I encourage you to respond to the invitation to comment on the draft ‘Protocols and Guidelines on Health Promoting Schools’ statement on page 145. Historical perspective The concept that schools have a role in promoting the health of young people is not a new one. The modern view of health promotion in schools can only be fully understood in the context of wider developments in health promotion in the last two decades. A move towards a general consensus on the meaning of the term health promotion was to a large degree the product of the work of Kickbusch and others advising the World Health Organization Regional Office for Europe. Their original discussion paper (WHO, 1984) laid out the broad concepts and principles of health promotion and helped to stimulate further debate. (Green & Raeburn, 1988). In addition a ground- breaking report in Canada (Lalonde, 1974) set out a model of health that was moving from a health care/disease-orientated one towards a social one. Over 125 years earlier reformers such as Rudolf Virchow in Germany (Virchow, 1848) and Edwin Chadwick in Britain (Chadwick, 1842) had been pioneers in Europe also setting out a social model of health and ideas on the role of the state in promoting health. Chadwick’s vision led to the Public Health Act of 1848 in Britain which set the principle of state responsibility for public health. (Acheson, 1990). In the 1980’s The Ottawa Charter for Health Promotion integrated current thinking, particularly in Canada and in WHO (Euro) and clarified the nature of health promotion (WHO, 1984). The Ottawa Charter defined health promotion as ‘the process of enabling people to increase control over, and to improve, their health’. This definition gave added scope and purpose to health promotion and had the potential to reconcile different viewpoints on the relative roles of the individual and society in the process of promoting health (Green & Raeburn, 1988). Some of the earlier writings on health promotion appeared to an extent to be rather dismissive of an educational approach. For example WHO’s discussion paper, referred to above, described health education as a core component of health promotion ‘which aims at increasing knowledge and disseminating information related to health.’ At the time this definition seemed narrow to educationalists and it ignored the affective and action domains which were part of education’s frames of reference at that time (Bloom, 1981). In addition it was implied that the subject exposed to this process of education is a relatively passive recipient of information. At the time many of us from an educational or pedagogical background felt that the value of an educational approach was in danger of not only being mis-represented, but that health education’s role could be under- valued. With hindsight this is interesting, as just prior to the birth of the modern model of health promotion, there were broader, more progressive views on health education around. For example in 1981 Kickbusch recognised the importance of developing competencies as well as transmitting knowledge. The view was also expressed that health education had to work not only at an individual level but had to interact with social, political and environmental factors that influence health (Kickbusch, 1981). As the new concept of health promotion emerged in 1984, the International Union for Health Education felt it was necessary to prepare a paper defending what it perceived as a misrepresentation of its core interest of health education. It also set out health education’s role within a Ian Young Guest Editor NHS Health Scotland Email: ian.young@health.scot.nhs.uk This Editorial is dedicated to the memory of Noreen Wetton who died in January 2006. Noreen’s pioneering draw and write technique, her energy and her wisdom inspired a generation of teachers across Europe to explore young children’s concepts of health as a starting point for curriculum development, learning and teaching. Please see page 147 for an illustration of her valuable work. editorial 113 IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 wider framework of health promotion (IUHE,1986). Most practitioners now recognise a broader concept of health education, which, interacts with the other components of health promotion. (Downie et al.,1990; Young & Whitehead, 1993). The IUHPE has now of course added the health promotion dimension to its area of interest and to its title. It is worth recounting this historical development because it is important to understand that the health promoting school was born at a time when there was a degree of scepticism that an educational approach in general, or schools in particular, could have much impact on the health of the population. The important role of schools is fully acknowledged in the United Nations Millennium Development Goals where one goal is specifically devoted to providing universal primary education and in several of the other goals schools have an important partnership role (United Nations, 2002). School health education and the health promoting school In 1985, the Scottish Health Education Group (SHEG) which was a collaborating centre for the WHO (European Office) was given the task of organising a European symposium in 1986 at Peebles, Scotland, attended by 150 delegates from 28 member states entitled “The Health Promoting School”. At this time Europe was effectively a divided continent and there were only 32 member states and there were also restrictions on travel from some of the eastern European countries. However with WHO assistance, senior staff from 28 member states were able to attend. At this event the concept of the Health Promoting School was developed and refined (Young, 1986). In fact the name ‘The Health Promoting School’ was born in the planning for the event although the concept had been evolving for several years and the literature in Europe had referred to the school as “a health promoting institution” in the two years prior to this. This symposium was significant because it offered the WHO Regional Office for Europe an opportunity to apply its developing theoretical model of health promotion to the setting of the school. From this event a report entitled ‘The Healthy School’ was produced on behalf of WHO (Young & Williams, 1989). The reason the name was amended was political at that time as the WHO Regional Office for Europe was keen to make links with its new Healthy Cities project. However you can’t keep a good name down for long, and the health promoting school soon bounced back into the forefront and gradually spread from its European origins to many parts of the world including Australia, New Zealand, Hong Kong and South Africa. The report described health promotion in schools as a ‘combination of health education and all the other actions which a school takes to protect and improve the health of those within it’. The health promoting school was considered as having three main elements: • The specific time allocated to health- related issues in the formal curriculum through subjects such as Biology, Home Economics, Physical Education, Social Education and Health Studies; • The ‘hidden’ curriculum of the school including such features as staff/pupil relationships, school/community relationships, the school environment and the quality of services such as school meals; • The health and caring services providing a health promotion role in the school through screening, prevention and child guidance. More modern ideas of the breadth of the health promoting school concept have since developed and further refined the thinking about the scope of the concept in Europe and beyond. The World Health Organization Office for Europe (WHO, 2005) has recently published a new strategy for child and adolescent health and development and this sets out aspects of the potential role of schools in the context of all the sectors which can impact on the health of young people. Comprehensive school health In the USA and Canada the terminology used to describe the processes relating to health in schools was and is different, and it is important to explore these terms and to reflect on the extent to which they reveal a different approach or if they are in fact closely related to each other. In the United States the history of public health had been fundamentally different from that of Europe. In Britain, for example, the medical profession had exerted control over public health from social reformers such as Chadwick in the middle of the 19 th century and by 1876 the leading universities such as Oxford, Cambridge and Edinburgh were offering public health qualifications exclusively for medical specialists. In the USA the first professors of Public Health in many Universities such as Yale were not from a medical background and this wider concept of public health may have been one factor in opening up other educational opportunities in the USA such as the availability of first degrees in health-related subjects which were not related directly to nursing or medicine. Barefooted children await their healthy soup in Edinburgh nearly one hundred years ago In the United States terms such as the ‘healthful school environment’ had been used since the early 1950’s indicating that there was an awareness of the importance of wider influences on health in schools beyond the ‘health instruction’ of the classroom. In the early 1980’s in the USA the phrase ‘comprehensive school health programme’ became the common term to encompass this broader approach. At that time this concept was considered to have the components of health instruction, the school health services and the school environment which was remarkably close to the European model in the same time period although using the different nomenclature of comprehensive school health programmes. In the 1990’s this broader concept of ‘comprehensive school health programmes’ was further developed in the USA and it was suggested the following components were part of this conceptual framework (Kolbe,1993). • school health education; • school health services; • school health environment; • school physical education programme; • school food service programme; • school psychology and counselling programmes; • programmes to protect and improve the health of staff; • integrated efforts of school and community agencies to improve the health of school and students. These components closely parallel the European model set out in The Healthy School Report (Young & Williams, 1989). The European model emphasised pupil participation more strongly than the USA approach but the European report also had some statements which now, with the advantage of research and hindsight, appear rather simplistic on the exemplar role of teachers and on the unquestioned role of self esteem in determining health- related behaviours. The European model has further developed to emphasise equity and democracy at the core of its activities (WHO, 1997) and this represents the egalitarian approach that had its origins in earlier European history. Perhaps the differences in terminology reflect this separate development, it was George Bernard Shaw who once remarked that Britain and America were two nations divided by a common language! However, I would conclude that these two models have much more in common than in their differences. This is interesting because to some extent they evolved independently of each other with only limited cross-fertilisation compared to the international contacts we can utilise today through electronic media. American school health colleagues such as Loren Bensley of Central Michigan University and the late Warren Schaller of Ball State University did visit Europe in the 1970’s and 1980’s and Tom O’Rourke of University of Illinois and Nick Iamarinno of Rice University have kept up this tradition to this day. Similarly Stanley Mitchell of the Scottish Health Education Group, Trefor Williams, University of Southampton, and Joos Van Hameren of the Netherlands Health Education Centre each had a study tour to North America at this time. These early innovators were the exception rather than the norm. In Europe today, with the possible exception of The Netherlands, there has been no significant adoption of the American language of comprehensive school health when discussing whole school effects. However, rather than focus excessively on the differences in approach, of greater interest are the similarities in the models and the fact that to some extent they represent convergent thinking on how the totality of the school experience can affect the health of young people, parents and staff. Phases of development in health promoting schools The issue of language is also important between the education and health sectors across the world. A feature of the development of health promoting schools and comprehensive school health systems is that the early innovators and proponents of change towards a whole school approach came from the health sector in most countries. The language of health promotion and the Ottawa Charter, or more recently the Bangkok Charter, (WHO, 2005) is now familiar to health professionals in many countries but it is not the language used by education professionals in most countries. To many progressive educationalists a term such as health promotion is not considered necessary in relation to schools because they may view the curriculum of a school as everything a school does and not merely the learning and teaching of the classroom (Young, 2002). This is not inevitably a problem in partnership working if all partners understand the others’ terminology and the concepts these terms describe. However, time has to be taken to explore these issues and this barrier has to be addressed. An additional barrier to progress is related to responsibility and authority. Ultimately health promoting schools are the education sector’s responsibility and the experience of the last twenty years has taught us that if schools are merely perceived as a convenient setting on which to impose a health promoting school model from the outside, then this is a limited and unsustainable approach in the longer term (St Leger & Nutbeam, 2000a). Where there has been a measure of success in spreading the health promoting school model at a regional, sub-national or national level, certain stages and features often appear. I wish to propose that they often include some or all of the following phases (Table 1) in countries where the concept of health promotion in schools has become more established: It is important to note that these phases are not always completely separate or discrete and that the centre and regions may be at different stages at any given time in one country. It has been my experience that some countries have reached the establishment stage where they have had the luxury of up to twenty years of development. Other countries with different levels of health problems and more limited investment or infrastructure in education are often in the first phase of development. Yet it would be misleading to suggest that progress always occurs in a simple linear way and in steady increments. It is of course highly political and rapid progress can be made when a strong political will exists. When the political priorities IUHPE – PROMOTION & EDUCATION VOL. XII, NO. 3-4 2005 114 To many progressive educationalists a term such as health promotion is not considered necessary in relation to schools because they may view the curriculum of a school as everything a school does and not merely the learning and teaching of the classroom [...]... maintain good health) ; • social actions (organised effort to influence healthy lifestyles and healthy environments); • healthy public policy and organisational practices, e.g., health cities, healthy schools and healthy workplaces); The above health promotion outcomes can modify the determinants of health Health promotion actions The health promotion actions can be classified as having three main ‘domains’:... effectiveness of health education and health promotion Patient Educ Couns, 30:7-17 World Health Organization (1986), Ottawa Charter for health promotion Journal of Health Prtomotion 1; 1-4 World Health Organization (1993) The health of young people: A challenge and a promise Geneva, Switzerland: World Health Organization World Health Organization (1995) Regional guidelines: Development of Health- Promoting... and accessibility to school health services The health promotion outcomes looked into the development of personal health skills to enhance health literacy, attitudes and values towards health, school health policies, features of school organisation which facilitated the implementation of health promotion, and any actions taken to create a healthy school environment The health promotion actions examined... K (2000) Promoting Mental, Emotional and Social Health: A Whole School Approach London: Routedge Wells J., Barlow J & Stewart-Brown S (2003) ‘A Systematic review of universal approaches to mental health promotion in schools’ Health Education, 103(4):220 WHO (1986) Ottawa Charter for Health Promotion WHO: Geneva WHO (1997) The Health Promoting School: An Investment in Education, Health and Democracy:... do we know about promoting mental health through schools? Abstract: There is a growing evidence base on what schools need to do to promote mental health effectively There is strong evidence that they need first and foremost to use a whole school approach This shapes the social contexts which promote mental health and which provide a backdrop of measures to prevent mental health disorders In this context... health promotion model These were Figure 1 Health and social outcomes The health and social outcomes represent the end-point of health and medical interventions such as mortality, morbidity; disability and dysfunction; health status; and social outcomes such as quality of life, life satisfaction and equity Intermediate health outcomes The intermediate health outcomes represent the determinants of health. .. outcomes represent the determinants of health such as: • healthy lifestyles (personal behaviours that protect or increase risk of ill health) ; • healthy environments (the physical environment and economic and social conditions that can impact directly on health and support healthy lifestyle); • effective health services Health promotion outcomes The health promotion outcomes could be summarised as follows:... positive models of mental health, which emphasise well being and competence not just illness– this will help overcome problems of stigma and denial and promote the idea of mental health as ‘everyone’s business’ The most effective programmes in schools which address mental health have the following characteristics: • They provide a backdrop of universal provision to promote the mental health of all and... included health topics 26.8 83.9 < 0.05* At least one staff trained or under training to promote health education 57.1 94.6 < 0.05* Provide diversified health education resources for staff, and such resources are well managed 58.9 78.6 0.043* Had healthy eating policy 57.1 100 < 0.05* Committee to monitor school healthy eating policy 75.0 96.4 0.002* School health promotion and health education Healthy... possibilities J Epidemiology and Community Health, 47, 123-127 Nutbeam D (1996) Health Outcomes and Health Promotion-Defining Success in Health Promotion Health Promotion Journal of Australia, 6(2): 58-60 Nutbeam D (1998) Evaluating health promotion – progress, problems and solutions Health Promotion International, 13(1), 27-44 Orloske AJ & Leddo JS (1981) Environmental effects on children’s hearing: IUHPE . with the health of staff as well as students, e.g. project on teacher mental health in Slovenia. • Strong element of concern for staff mental health and for training, e.g. Manual ‘Promoting Mental, . equity. Intermediate health outcomes The intermediate health outcomes represent the determinants of health such as: • healthy lifestyles (personal behaviours that protect or increase risk of ill health) ; • healthy. impact directly on health and support healthy lifestyle); • effective health services. Health promotion outcomes The health promotion outcomes could be summarised as follows: • health literacy (the