Vancouver, British Columbia

1

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

• Vancouver, British Columbia
• June 5-8, 2007

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Presentation

• Purpose, Methods, Countries
• Definitions Research-based Implementation
  Processes
• Highlights Case Study Findings
• Recommendations

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Part I

• Purpose, Methods
• Countries Providing Case Studies

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Purpose

• Provide learnings for future efforts
• Foster a learning community
• Provide guidance to WHO, FRESH partners and
  others to strengthen implementation in next
  decade.

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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 learnings from case
  studies in context of research on implementation
• Case study authors commented on other cases.

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WHO Regional Offices
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Cases 17 from 6 WHO Regions
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Case studies address

• Contextual situation of implementation
• Programme elements results
• Implementation processes and activities
• Recommendations implementation

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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

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WHO consultation in Zhejiang Province, China.
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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.

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Children exercising as part of HPS in China
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Improved Food Services, Zhejiang Province
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A teacher in Zhejiang Province, China measures a
students height and weight
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Scope and Scale of CasesUnited 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
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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

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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.

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Part II

• Definitions Research-based Implementation
  Processes

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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.
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Definitions

• Dissemination
• Diffusion
• Technology Transfer

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Importance of Implementation Research

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

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Implementing HPS Concept Requires Many Capacities
Processes
Adapted from WHO and EDC (unpublished).
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Social Ecological Framework
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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.

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Research-based Implementation Processes that can
Change Policy and Practice
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Selected Implementation Research Findings

• National guidelines on proven clinical practice
  10 increase physicians adopting it2
• Concerns based adoption 80 of attention to
  concerns or only 20 chance of success3
• 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
284291. 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.
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Selected Implementation Research Findings

• Importance of outside influences.5
• Large changes more than small, incremental ones5
• Review 39 studies on endurance for education
  reform change leader, school-wide non small
  scale participation6
• Thai study school reform noted 3 effective
  practices continuous internal supervision
  exchange of ideas experiences community
  participation7

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.
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PART III

• Highlights Case Study Findings

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

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

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

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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

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

• Bahrains vision for School Health Program
  stated simply, All children and youth living
  healthy, active lives.
• Bahrain Mariam Al-Mulla Harmas

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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

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Datas 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 Scotlands 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.
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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

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Datas 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.
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Hong Kong
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Datas 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.

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Decision Makers Consider Research Results and
Scaling Up.
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Stakeholder Ownership Participation

• Ministry School Community Student Levels

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Ministry Level Ownership Participation Nigeria
RAAPP
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Participation Led to Bore Hole Water Pump
Implementation
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Uruguay ownership by education sector

• From the start, we were
• striving to place the HPS
• at the heart of education
• Policies institutions.
• Education sector
• ownership was core to
• Implementation.
• Sergio Meresman

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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

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nz.26.0.html?tx_jppageteaser_pi15bbackId5d19
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School Community LevelSouth 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
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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. Lango, B.B. Jensen

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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.

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Tools to Foster School Community Participation
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Cross-Sector Collaboration

• Ministries of Health, Ministries of Education
• and more

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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.

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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.

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Singapore Cross-Sector Collaboration

• After 5 years, CHERISH award now included in
  MOEs master plan
• Health Promotion Board Ministry of Education
  have become greater partners in expanding to more
  schools.

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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.

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Leadership and Champions

• China Everything can be done if leadership
  pays attention to the issues.

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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.

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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.

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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)

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Cycle of Implementation
Post implementation
Introduction of innovation
Current practices may drop
New practices are implemented and overall
practice exceeds pre-innovation levels
Typical period for
evaluation
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Tools were invaluable in process of
implementation

• Professional Development, Materials, Learning
  Communities

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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.

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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.

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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.

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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

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Contact Information

• Cheryl Vince Whitman, Senior Vice President, EDC,
• Director, Health and Human Development Programs
• Director, WHO Collaborating Centre
• cvincewhitman_at_edc.org
• Direct Office Line 617-618-2300
• Mobile [phone]
• 55 Chapel Street, Newton, MA, USA 02458-1060
• www.edc.org www.hhd.org