Vancouver, British ColumbiaJune 5-8, 2007

WHO Technical Meeting: Building School Partnerships for Health, Education Achievements and Development

Track 2 Paper: Health Promoting Schools Case Study Experiences of Implementation

Cheryl Vince Whitman with special acknowledgement to Sergio Meresman, Carmen Aldinger and Case Study Authors

Presentation

I. Purpose, Methods, Countries

II. Definitions & Research-based Implementation Processes

III. Highlights: Case Study Findings

IV. Recommendations

Part I

Purpose, Methods Countries Providing Case Studies

Purpose

Provide learning’s for future efforts;

Foster a learning community;

Provide guidance to WHO, FRESH partners and others to strengthen implementation in next decade.

Methods

Conducted literature review of research on implementation, diffusion of innovation, & education reform;

Solicited country case studies through 6 WHO Regional offices;

Synthesized literature and learning’s from case studies in context of research on implementation;

Case study authors commented on other cases.

WHO Regional Offices

Cases: 17 from 6 WHO Regions WHO Region Country Author

Africa Kenya

Mauritius

Nigeria

South Africa

W. Onyango-Ouma, D. Lang’o and B. B. Jensen

Odete Cossa

Dr. Olushola Odujinrin

Bruce Damons and Sean Abrahams

The Americas Uruguay Sergio Meresman

Europe Germany

Scotland

Peter Paulus

Ian Young

Eastern Mediterranean Bahrain

United Arab Emirates

Mariam Al-Mulla Harmas

Miram Al Matroushi

South-East Asia Maldives Hussain Rasheed

Western Pacific China

Cook Islands

Hong Kong

Laos

Philippines

Singapore

Viet Nam

Carmen Aldinger

Kia Manuia, Karen Tairea and Debi Futter-Puati

Albert Lee

Ly Foung, Phoungkham Somsanith and Khattanaphone Phandouangsy

Sheila R. Bonito and Ma. Lurenda S. Westergaard

Rose Vaithinathan

Margaret Sheehan, Dr. Nguyen Huy Nga, Dr. Nguyen Hung Long, Dr. Le Thi Thu Hien, Dr. Le Thi Kim Dung, Mrs. Bui Phuong Nga and Bernie Marshall

Case studies address:

Contextual situation of implementation;

Programme elements & results;

Implementation processes and activities;

Recommendations: implementation

What was the impetus for action?

Data health or education outcomes;

Globalization & challenges;

Recognition link education & health;

Economic or other hardships;

Schools as sites for remediation and services;

Guidelines/consults: WHO/FRESH

WHO consultation in Zhejiang Province, China.

Scope and Scale of Cases: China: Zhejiang Province 51 schools: 93,000

students & families;

6800 staff;

Primary, junior, senior, vocational levels

Multiple components of HPS implemented.

Children exercising as part of HPS in China

Improved Food Services, Zhejiang Province

A teacher in Zhejiang Province, China measures a student’s height and weight

Scope and Scale of Cases:United Arab Emirates Dates back to 1968;

Addresses all 8 components;

2004-2005, 512 nurses, 106 physicians reached 745 governmental schools (287,098 students) & 10 referral clinics;

Same staff supervised implementation in 480 private schools reaching 345, 535 students.

www.ibm.com/.../04/me_en_v14_news_20060419.html

Scope and Scale of Cases: GermanyAnschub.de (2002-2010) Involve students in ‘Good and Healthy

Schools’ nationwide;

Multiple components;

4 of 16 Bundeslander (provinces);

Alliance of 60 national organizations to support spread;

Scope and Scale of Cases: Kenya

2 strands: health education and health education and & student participatory approaches can alleviate helminth infections;

9 primary schools in one district; classes 4 & 6 reaching 536 students.

18 teachers and 9 head teachers trained.

Part II

Definitions & Research-based Implementation Processes

Implementation

“A specified set of activities designed to put into practice an activity or programme of known dimensions.”1

“Activities are purposeful and described in sufficient detail such that independent observers can detect the presence and strength of the specific set of activities.”1

1. Fixsen, Dean, L. et al, Implementation Research: A Synthesis of the Literature. USF University of Southern Florida, Tampa, Florida, 2005.

Definitions

Dissemination

Diffusion

Technology Transfer

Importance of Implementation Research

Most research has focused on effectiveness of the intervention, rather than on the effectiveness of the implementation process.

Implementing HPS Concept Requires Many Capacities & Processes

Adapted from WHO and EDC (unpublished).

Social Ecological Framework

Social-Ecological Levels

From Ian Young, Scotland:“Different levels of the system have to play a part. For example, national government (education, health and other government departments), area health boards, Local education authorities, individual schools, school managers, teachers, parents and young people.)”

“At some points, we have had a top down approach; at other times the drive has come from young people, parents or the exemplary work of specific area health authorities, individual schools or education authorities.”

Research-based Implementation Processes that can Change Policy and Practice

Vision & Concept

International & National

Guidelines

Champions & Leaders at All

Levels

Administrative &Management Support

Data-DrivenPlanning &

Decision Making

Team Training &Ongoing Coaching/

Learning CommunityCritical

Mass & Supportive

Norms

DedicatedTime &

Resources

Attention to External Forces

Adaptation toLocal Concerns

Key Factors in Changing Policy and Practice

Stage of Readiness

Stakeholder Ownership & Participation

Mechanisms for Cross-Sector Collaboration

Produce Changes in Policy &

Practice

Selected Implementation Research Findings

National guidelines on proven clinical practice = 10% increase physicians adopting it;2

Concerns based adoption: 80% of attention to concerns or only 20% chance of success;3

‘Change agent effort, whether [by] the leader or [by] her designee, is known to be a predictor in the rate of diffusion.4

2. Cohen, S., Halvorson H.W. and Gosselink, C.A. (1994) ‘Changing physician behavior to improve disease prevention’ Preventive Medicine, 23: 284–291.3. Loucks-Horsley, S. (1996) ‘Professional development for science education: a critical and immediate challenge’ in Bybee, R. (ed) National Standards and the Science Curriculum, Kendall/Hunt Publishing Co. 4. Rogers, E.M. (1995) Diffusion of Innovations, 4th edition, Free Press.

Selected Implementation Research Findings

Importance of outside influences.5

Large changes more than small, incremental ones;5

Review 39 studies on endurance for education reform: change leader, school-wide non small scale; participation;6

Thai study school reform noted 3 effective practices: continuous internal supervision; exchange of ideas & experiences’ & community participation;7

5. Berman, P. and McLaughlin, M. (1975) ‘The findings in review’ Federal Programs Supporting Educational Change, IV, The RAND Corporation.6. Greenfield, T. A. ‘Improving chances for successful educational reform.’ (1995) Education. 115 Issue 3: 464.7. Khemmani, T. ‘Whole-School Learning Reform: Effective Strategies From Thai Schools.’ (2006) Theory Into Practice. Vol. 45 Issue 2: 117.

PART III

Highlights: Case Study Findings

International Guidelines

2000, Dakar, Senegal, World Education Forum, Education for All Assessment

1995, Geneva, Switzerland, WHO Expert Committee on Comprehensive School Health Education and Promotion

1995, Geneva, Switzerland, WHO Expert Committee on Comprehensive School Health Education and Promotion

International Guidelines

Guidelines were significant in moving from a narrow view of school health as primarily health education or curriculum to multiple components of HPS or FRESH: policy, skills-based curriculum, services, psycho-social and physical environment.

Influence of Guidelines:

“As we grew in our understanding of the HPS concept, we resolved to implement all five pillars and to adapt them to our unique conditions.”

- Bruce Damons, Sean Abrahams, - Eastern Cape, South Africa

Vision and Concept: Cook Islands, Kia Manui, Karen Tairea, Debi Futter-Puati

The Oe represents Kopu tangata (Social well being). How you use your paddle makes life smooth or difficult; if more than one person is paddling a vaka the paddles need to be in harmony.

The twine, or Ka’a, binding together the parts of the vaka, needs to be very strong. The Ka’a represents the resiliency we want for young people, resiliency is the set of skills needed to be able to withstand life’s challenges.

The Ama represents Vaerua (Spiritual well being). The ama balances the canoe in rough weather, your values and beliefs help to give balance in your life.

Aorangi is the conditions the vaka finds itself in. Whatever the environment, you must be equipped to handle it and understand its influence on your journey.

The Vaka symbolises Kopapa (Physical well being). The hull is the “body” of the vaka, and where the paddlers sit.

The Kie represents Tu Manako (Mental and Emotional well being). What you put in your sails determines what path you take and how you handle situations.

Vision and Concept

“Bahrain’s vision for School Health Program stated simply, ‘All children and youth living healthy, active lives.”

Bahrain: Mariam Al-Mulla Harmas

Vision and Concept:

“To ensure that the school is used as an instrument to develop not only the learners but also parents and the community. This can be done if the school serves as the center of educational social transformation.”

Bruce Damons, South Africa

Data’s Role - National Policy: Scotland

The HBSC is a unique data set on health of adolescents in Scotland over 16 years.

E.g., Gender & socio-economic inequalities are evident in health behaviours. Girls are less positive about their own health & well-being, suffering more frequently from complaints, including feeling low.

These data played a part in leading to specific developments in practice, policy and legislation.8

8. Alexander, L., Currie, C., Todd, J., Smith, R. (2004). How are Scotland’s Young People Doing? A Cross-national Perspective on Physical Activity, TV Viewing, Eating Habits, Body Image and Oral Hygiene. HBSC Briefing Paper 7. Edinburgh: Child and Adolescent Health Research Unit, University of Edinburgh.

Data-driven Planning & Decision Making

“Today, Health Promoting Schools in Scotland are relatively well established as mainstream in the education sector.

In 2006, Scotland also introduced the act of parliament, “Schools” Health Promotion and Nutrition (Scotland) Bill, which is anticipated to become law in summer 2007. Data and the university partnership for research have made a difference in getting to this point.”

Ian Young, Scotland

Data’s Role: Hong Kong

Surveillance on 26,111 students aged 10 to 19 drawn from 48 primary & secondary schools.[9]

Results revealed 14% of students felt that their physical health and emotional health had interfered with normal daily activities; 15% of students had consulted doctors more than 3 times over the last six months; 15% described themselves as regular smokers.9

Results brought together Chinese University of Hong Kong and Schools Council to move beyond curriculum to 6 components now reaching 210 schools.

9. Lee A et al (2007). Guidelines for Developing Health Education Curriculum for Kindergartens (Chinese). Centre for Health Education and Health Promotion of the Chinese University of Hong Kong and Department of Early Childhood Education of Hong Kong Institute of Education.

Hong Kong

Data’s Role: Lao & China

Data indicating high incidence of helminthes led to launch of HPS in 30 schools. A MOU between the MOH & MOE increased implementation to 450 schools.

In China, effectiveness of school health programs in reducing worm infections led to broad scaling up of all components throughout Zhejiang province.

Decision Makers Consider Research Results and Scaling Up.

Stakeholder Ownership & Participation:

Ministry; School & Community; Student Levels

Ministry Level Ownership & Participation: Nigeria RAAPP

Participation Led to Bore Hole Water Pump Implementation

Uruguay: ownership by education sector

“ From the start, we werestriving to place the HPSat the heart of educationPolicies & institutions.Education sectorownership was core toImplementation.”

Sergio Meresman

Germany: Good and Healthy Schools Student, Teacher, Parent Participation

Health promotion must contribute to educational outcomes;

Self-Evaluation in Schools: surveys to assess priorities;

Findings used to select modular interventions.

Dr. Peter Paulus

http://www.toolbox-bildung.de/Fach-und_Sachkompetenz.26.0.html?&tx_jppageteaser_pi1%5bbackId%5d=19

School & Community Level:South Africa

“The golden thread, the glue was community participation and ownership, a key element of the HPS concept. We were congratulated for having actual and concrete proof of community involvement rather than theorizing about the concept.”

- Bruce Damons, Sean Abrahams, South Africa

Kenya: Student Participation & Action

Health Clubs and Flip Chart Methods

“Remarkable changes took place in students’ personal & environmental hygiene. Students burned and sold charcoal to buy shoes to prevent helminth infections.”

W. Onyango-Ouma, D. Lang’o, B.B. Jensen

United Arab Emirates: rural schools

Staff, parents and students actively worked together on situational assessments, porgram design;

Close, active participation succeeded in changing community attitudes and way of looking at the school as pure education institution to one that can change overall lifestyles & living conditions.

Tools to Foster School Community Participation

Cross-Sector Collaboration

Ministries of Health, Ministries of Education

and more ……

Cross-Sector Collaboration

Many report barriers & difficulties, but all 17 cases achieved collaboration;

Ministry of Health often began, but eventually made partnership with Education;

Must overcome differences in language, concepts, training and orientation.

Cross-Sector Collaboration requires..(Ian Young)

Time, commitment & persistence;

Trust-building building of trust;

Development of mutual understanding on language, concepts and values;

Agreement on budget and roles;

Accepting challenges to traditional professional roles.

Singapore: Cross-Sector Collaboration

After 5 years, CHERISH award now included in MOE’s master plan;

Health Promotion Board & Ministry of Education have become greater partners in expanding to more schools.

Cross-Sector Collaboration

Almost all originated with MOH but could not move to scale until formal collaboration developed with MOE;

In 1999, Ian Young reports, “Finally, there was evidence of the education sector taking the ideas of the health sector and running with them”.

Leadership and Champions

China … “Everything can be done if leadership pays attention to the issues”.

Leadership & ChampionsChina: “paying attention”

Principals received programmatic & financial support from education bureau;

HPS got much attention from leaders;

When municipal support lacking, principal leadership very helpful.

Stages in HPS Development

I. Initial Experiment (often initiated by MOH);

II. Strategic Development (education starts to

perceive benefits);

III. Establishment where partnership & innovation firmly embedded working of school.

Tracking & Monitoring Results

National capacities in place: MoUs; policy, training;

# schools meeting criteria for HPS awards (Singapore/Europe);

Child health indicators (Lao);

Changes in surrounding school environment, e.g. latrines, water pumps (Nigeria, Kenya);

Cycle of Implementation

Introduction of innovation

Current practices may drop

Typical period for evaluation

New practices are implemented and overall practice exceeds pre-innovation levels

Post implementation

Tools were invaluable in process of implementation

Professional Development, Materials, & Learning Communities ……

Weakest Implementation Strategies

Staff development & teacher training to implement multiple components & curriculum;

Advocacy strategies not discussed very much;

Too long, too late to involve education and for education to perceive benefits of health promotion and disease prevention.

Recommendations

Guidelines that focus actions and international learning communities on strategies for implementation and an agenda for implementation research;

Improving strategies for partnerships with education, health and others. Develop ways to gain a shared language, concepts, and perceived benefits.

Data was key to successful implementation: strengthen ways at national and local levels to collect & use data in planning, intervention design are critical. Use data in advocacy techniques.

Recommendations

Ownership has proven to be one of the most important factors. How can WHO/FRESH disseminate more of the tools and practices that have been used to gain buy-in and participation, including the active role of students?

Weakest element appears to be staff and teacher pre-service and in-service professional development. Training must address not just health and curriculum, but school management for whole school approach parallel to education reform.

HPS+: transformation of concept of schooling, links to educational outcomes and community. Not just schools as a setting for health promotion.

What really matters in implementation

“What makes health promotion sustainable in schools is integrating it into existing policies aimed at improving teaching and learning and the whole school environment and putting it in the hands of those who live and construct everyday life in schools.”

Sergio Meresman, Uruguay

Contact Information

Cheryl Vince Whitman, Senior Vice President, EDC,

Director, Health and Human Development Programs

Director, WHO Collaborating Centre

cvincewhitman@edc.org

Direct Office Line: 617-618-2300

Mobile: 857-928-6144

55 Chapel Street, Newton, MA, USA 02458-1060

www.edc.org; www.hhd.org