Health Behaviour in School-aged Children and Health Promoting School Macedonia

1. Health Behaviour in School-aged Children and Health Promoting School Macedonia Lina Kostarova Unkovska, PI for HBSC Study Macedonia Center for Psychosocial and Crisis Action

2. Republic of Macedonia is a small multi-ethnic country in the Balkans with a population of approximately two million and a GDP of US$ 9200. 69% of people are ethnic Macedonians, 23% are ethnic Albanians and the rest are Turks, Roma, Serbs ets. Forty-six per cent of families live on low household budget and the unemployment rate is 34%. The 18 years following the country’s independence have been marked by armed conflicts, refugee crises and rapid changes in all spheres of the political and social life.

3. The whole generation of young people has been brought up in conditions of poverty and distrust in others and in their own future.

4. Macedonia is also, a small beautiful mountain and lake country, with about 2000 medieval churches and monasteries, organic products, untouched nature, excellent food and friendly people… and it is difficult not to like it. For the visitors it remains a destination to always come back to… Macedonia is a site of contradictions, where people learn how to live, becoming stronger and more capable perhaps in coping with whatever might come in the future..

5. Children are something different … • They are in the permanent need of: • Safe, stimulating and supportive environment • Freedom to play, improvise and act • To be listened to and heard • Caring community where they can participate • Social networks (of peers and adults) to share and discuss their ideas, concerns, and experiences • All these needs as well as children’s rights can not be postponed. They must be met on time in order for a child to grow well and healthy.

6. Health Behaviour in School-aged Children: А World Health Organization CollaborativeCross-national Study – www.hbsc.org Health Behaviour in School-aged ChildrenStudy • International Survey run every fourth year in increasing number of countries (44) of Europe, North America, Canada and Russia • 2006 Sample with over 200.000 school children - 11,13,15 y. • Two Coordination Centers: Edinburgh & Bergen, and 44 national research teams.

7. Health Behaviour in School-aged Children: А World Health Organization CollaborativeCross-national Study – www.hbsc.org Health Behaviour in School-aged ChildrenStudy The HBSC considers young people’s health in its broadest sense, encompassing physical, social and emotional wellbeing without focusing exclusively on risk health behaviours, or absence of disease; thus health is viewed as a resource of everyday living. HBSC studies the social context of health including family, school and peers, including the local area and socio-economic environment in which young people grow up, in order to understand fully the patterns of health and health behaviour in adolescents,through comparisons of children of the same age in various parts of the world.

8. Health Behaviour in School-aged Children: А World Health Organization CollaborativeCross-national Study – www.hbsc.org The HBSC data is young people’s data – it is their thoughts, experiences, aspirations and concerns which will govern the actions that emerge from it. The ethos of the HBSC Study is that the participating young people are not “subjects” to be studied, but rather they are partners in creating a data base that will influence the actions of policy-makers, public health experts, teachers, parents and other key stakeholders in the countries in which they live. Their participation provides deep and meaningful insights into what it is like growing up as a young person today.

9. Health Behaviour in School-aged Children: А World Health Organization CollaborativeCross-national Study – www.hbsc.org • The effects of the study • In most Member States of the WHO European Region, there is a lack of systematic data collectionsystems in relation to young people aged 11–15 years, and HBSC goes a considerable way towards filling the gaps. • An important effect of the HBSC study has been to inspire an increasing number of countries to strengthen their capacity for data collection, analysis and utilization in this domain. • We are also witnessing an increased utilization of HBSC data in reviewing existing policy and generating new policy at country level.

10. Health Behaviour in School-aged Children: А World Health Organization CollaborativeCross-national Study – www.hbsc.org • Instruments • Core questionnaire – 122 items /obligatory for all countries/ • Optional packages – covering fields of special interest in children health of the individual country • Protocol – both core and optional questionnaires, procedures for sample construction, rationales for various research fields, and guidance for the study application and data administration… • A core set of Study questions are looking at: • Demographic characteristics (age, sex, parents' professions and household structure); • Socio - economic status; social inequality; • Health-related behaviour(cigarettes, alcohol, narcotics, prescribed drugs usage, physical activity, diet, dental hygiene, leisure time activities, bulling, violence etc.) • Subjective (mental) health /well-being/ and psycho-somatic complains; • Social health (relations within family, and with peers) • School related experience(satisfaction with school and school atmosphere, participation, possible harassment, etc);

11. Health Behaviour in School-aged Children Study in Macedonia • Macedonian HBSC History • Three cycles of the study 1998, 2002, 2006 towards the fourth cycle in 2010 • National sample - 5160 pupils • Two sub-samples of Macedonian and Albanian language speaking children in three age groups 11, 13, 15 • Coordination • All study cycles were carried out by the same research team at the Center for Psychosocial and Crisis Action, with support from various national and international bodies…

12. Health Behaviour in School-aged Children Study in Macedonia • Macedonian children’ health profile • in comparison to other children from Europe, North America and al. • 92% of children live with both parents • More easy to talk to their mother and father • Spend more time after school and in evenings (15y.) with friends • Like school a lot • Find their school-mates kind and helpful • Smoke, drink and get drunk less than their European peers • Watch less TV and Videos, and are physically quite active • Feel happy • And fights …

13. Young people who like the school a lot (%)

14. Health Behaviour in School-aged Children Study in Macedonia When focusing on poverty…

15. Health Behaviour in School-aged Children Study in Macedonia Context-related approach to children’s health and wellbeing Health risk behaviors related to children’s poverty …

16. Health Behaviour in School-aged Children Study in Macedonia Context-related approach to children’s health and wellbeing Mental health and the social inequality related to poverty, children’s age, gender and ethnic background - key predictor for children long-term poor health outcomes - Proportion of pupils feeling unhappy (%)

17. Health Behaviour in School-aged Children Study in Macedonia Context-related approach to children’s health and wellbeing Mental health in children from affluent and poor families Proportion of pupils not being able to pay attention during the past week (%) Pupils feeling lack of energy during the past week (%)

18. Health Behaviour in School-aged Children Study in Macedonia Trends in violent behaviour among adolescents unhealthy response to social inequality Young people who participated in fights over the last 12 months (%) 2002 / 2006 comparison

19. The country under permanent change and children wellbeing Impact of poverty and social inequlity on children and youth • In transitional countries - poverty, tensions and uncertainty about the future are among the key determinants and predictors of health in people • Within such conditions the social inequality in youth increses, predominantly and ireversibly affecting their health and development • The trends of increasing violent and other risk behaviors in adolescents can be stoped only if they are recognized as children’s unhealthy response to long-term diverse living conditions and marginalisation. Instead of focussing on problem behaviour and discipline / penalty measures, the youth policies should focus on creation of safe and supportive environments for young people participation and their meaningful integration in the society.

20. The country under permanent change and children wellbeing The HPS initatives and actions in communities under risk, should be the key System’ response towards more active involvement of children in a comunity actions, thus increasing their competent and democratic participation in health promotion.

21. Health Promoting School Macedonia • 1995 - a network with 10 schools established • 1996 - an extensive training programme for School Educators to disseminate the idea of a HP School, was implemented • 1997 - the network expanded with another 13 schools and the school project teams were trained in the IVAC (Investigation, Vision, Action & Change) Danish approach to school health promotion, which assumed increased inclusion of children in health promoting projects and their empowerment for active participation, guided and supported by competent adults… • 1999, the NATO bombardment resulting in the Kosovo refugee crisis, with 16.000 refugee children over flooding Macedonian schools, created a different context for HPS project realization… • 2001- interethnic arm conflict in Macedonia, which ended up with the Ohrid Agreement, together with the long-term impoverishment in all segments of people’s life, determined the further strategy of HPS towards creation of a safe and stimulating environment for joint pupils’ and teachers’ participation in building of a multiethnic community, as a basic preconditions for health.

22. Health Promoting School Macedonia • Thus, the HPS project became an opportunity for developing strategies for coping with critical life conditions. This gave a new meaning to the concept of school health promotion, focusing on: • Pupils’ participation • Mental and emotional health • Psychosocial Actions in managementof the crises

23. Health Promoting School Macedonia Based on a holistic concept of health and its key components, the HPS in Macedonia today operates through various projects and programs under different names and in a variety of contexts. The achieved sense of competence, democratisation, and control over the situation, as part of the commitment to continual learning and development, has become the main directions towards the success.. . The projects which run within or in between the schools, are initiated by pupils and teachers on variety of health issues, as well as on the subjects of children’ / adults’ priorities and concerns /tobacco smoking, children’s rights, joint dictionary, games: boys& girls, the other, linking & networking, mental health, safe school etc./ No matter of the subject initiated, researched, and acted upon, the project’s focus remains on the same basic principles of freedom within limits, safety, equal participation, process democratization, cooperation and networking.

24. Health Promoting School Macedonia “School networks – communities for multicultural development” Case study The Project sees schools as relevant participants in the building of a safe and dynamic social field of inter-cultural exchange, respect and understanding. The overall aim of the project was to empower schools to assume new roles and responsibilities in promoting the well-being of children in the multiethnic community. Its main objectives were to improve schools’ competencies in creating new approaches of cross-regional networking and cooperation through joint pupils’ and teachers’ projects, on various subjects of their key interests. In turn this would increase school democracy and young peoples' joint participation in a multicultural community development.

25. Health Promoting School Macedonia “School networks – communities for multicultural development” The project evaluation and lessons learned • In two years, the Project succeeded in networking 19 schools, • those from the post-conflict (multi-ethnic) region of the country • with schools from the Health Promoting Schools Network, as • well as rural schools with those in urban areas. • Three areas of change were identified as a result of the pupils • and teachers evaluation of the project through focus group • discussions, which were run in each of the project schools: • changes in myself • changes in our relations to others • changes in my environment

26. Health Promoting School Macedonia The project evaluation and lessons learned • I can see myself changing ... • “We were learning something new every time we met...I’ve learned to listen to others, and I have to admit I didn’t do it often before “.. (Pupil from K.J.Pitu,Skopje) • “The greatest benefit is to learn how to cope with different situations. You acquire certain confidence, courage, and self-assurance that we can run the projects on our own …” we apply for our own projects, rather than wait for projects to come from the outside (Teacher from Kiril I Metodij, Tetovo) • Changes occur in our relationships too … • “When we went to the Roma we learned about their origins and about their culture. … We believe that school is important, that it will help us later to get on in life, and the Roma don’t hold that view. … We thought that all Roma are bad, but most of them are good. We thought that Roma lacked education, since they don’t go to school, but there are many smart Roma …” (A pupil from Kiril I Metodij, Kocani) • “The experience in bonding with the school in Kavadarci meant a lot, and now I feel as if it was my own school. It also enabled us to see where we stand in comparison with the other schools in the country, as well as to those in Denmark and in Argentina …” And we can do better, we are not so bad…(Teacher from A.S.Kikish)

27. Health Promoting School Macedonia “School networks – communities for multicultural development” The project evaluation and lessons learned • “This project has brought us closer to Macedonians; we were not friends before, and now we have good relations, we talk to each other. We were supposed not to associate with pupils of the other group – people were wondering, ‘look at him, he’s being friends with a Macedonian’. Even about the project, they say: ‘I’m not going, there are Macedonians there’. I don’t respond to things like that any more, but rather go on my way. ... Now we speak Macedonian better and feel more at ease using it ...” (Pupil of Albanian origin, from Bratstvo Migeni, Tetovo)

28. Health Promoting School Macedonia The project evaluation and lessons learned • There are changes in the school and in the community • “As a team of 12 we function impeccably. … We always find free time, it is not easy but we manage to meet at least once a week. … We each have our own areas and activities, and when we meet we exchange experiences and have a lot of fun …” (Teacher from Kliment Ohridski, Bitola) • “I use in the instruction everything we learned in the project: we research, present. Children don’t necessarily have to know that we teach according to the S-IVAC approach, but we do follow the same steps and procedures” (Teacher from Goce Delcev, Kavadarci) • “When the school psychologist invited me to join the Project, I thought I was not going to like it, but I got interested as soon as we started researching … we identified the things that we objected to and which needed to be changed … Step by step we are changing certain things, even in the school, I could no believe this is possible ever…” ( Pupil from K.J.Pitu, Skopje)

29. Health Promoting School Macedonia The “School networks – communities for multicultural development” The project evaluation and lessons learned • From multilevel empowerment outcomes to their influence on sustainable development: • The Rifkin acronym “CHOICE”, following six critical areas of measurement in support of community empowerment programmes was used to explore the capacity of this Project in regard to its sustainable development outcomes… • capacity building • human rights • organizational sustainability • institutional accountability • community contribution • enabling environment

30. Health Promoting School Macedonia The “School networks – communities for multicultural development” The project evaluation and lessons learned The project’s major achievements remain in the psychosocial area - that is, pupils’ and teachers’ participation, children’s rights, competences, and processes of democratization. There is also partial achievement of structural and organizational changes in the project schools. The main weakness of this kind of Projects is that it largely depends on positioning within the System. The sustainability of the outcomes will depend on additional investment in the areas of: institutional accountability, wider community contribution and further development of an enabling environment. These are the vital system areas, and the most difficult to reach and influence from the position and operation of individual schools.