Vancouver, British Columbia June 5-8, 2007

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

2. Presentation • Purpose, Methods, Countries • Definitions & Research-based Implementation Processes • Highlights: Case Study Findings • Recommendations

3. Part I Purpose, Methods Countries Providing Case Studies

4. 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.

5. 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.

6. WHO Regional Offices

7. Cases: 17 from 6 WHO Regions

8. Case studies address: • Contextual situation of implementation; • Programme elements & results; • Implementation processes and activities; • Recommendations: implementation

9. 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

10. WHO consultation in Zhejiang Province, China.

11. 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.

12. Children exercising as part of HPS in China

13. Improved Food Services, Zhejiang Province

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

15. 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

16. 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;

17. 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.

18. Part II Definitions & Research-based Implementation Processes

19. 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.

20. Definitions • Dissemination • Diffusion • Technology Transfer

21. Importance of Implementation Research Most research has focused on effectiveness of the intervention, rather than on the effectiveness of the implementation process.

22. Implementing HPS Concept Requires Many Capacities & Processes Adapted from WHO and EDC (unpublished).

23. Social Ecological Framework

24. 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.”

25. Research-based Implementation Processes that can Change Policy and Practice

26. 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.

27. 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.

28. PART III Highlights: Case Study Findings

29. 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

30. 1995, Geneva, Switzerland, WHO Expert Committee on Comprehensive School Health Education and Promotion

31. 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.

32. 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

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

35. “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

36. 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

37. 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.

38. 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

39. 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.

40. Hong Kong

41. 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.

42. Decision Makers Consider Research Results and Scaling Up.

43. Stakeholder Ownership & Participation: Ministry; School & Community; Student Levels

44. Ministry Level Ownership & Participation: Nigeria RAAPP

45. Participation Led to Bore Hole Water Pump Implementation

46. “ 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 Uruguay: ownership by education sector

47. Health promotion must contribute to educational outcomes; Self-Evaluation in Schools: surveys to assess priorities; Findings used to select modular interventions. Dr. Peter Paulus Germany: Good and Healthy Schools Student, Teacher, Parent Participation http://www.toolbox-bildung.de/Fach-und_Sachkompetenz.26.0.html?&tx_jppageteaser_pi1%5bbackId%5d=19

48. 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

49. 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

50. 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.