Health promoting schools in England--a way forward in development

Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial

Background

Evidence suggests that dietary intake of UK children is suboptimal. As schools provide an ideal natural environment for public health interventions, effective and sustainable methods of improving food knowledge and dietary habits in this population must be identified. Project Daire aimed to improve children’s health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions.

Methods

Daire was a randomised-controlled, factorial design trial evaluating two interventions across four arms. Primary schools in Northern Ireland were randomised to one of four 6-month intervention arms: i) ‘Nourish’, ii) ‘Engage’, iii) ‘Nourish’ and ‘Engage’ and iv) Control (Delayed). ‘Nourish’ was an intervention aiming to alter the whole-school food environment, provide food-related experiences and exposure to locally produced foods. ‘Engage’ was an age-appropriate, cross-curricular educational intervention on food, agriculture, nutrition science and related careers. Primary outcomes were emotional and behavioural wellbeing and health-related quality of life. A number of secondary outcomes, including dietary intake, cooking competence and food-related knowledge, were also measured.

Results

Fifteen schools from areas of varying socio-economic status participated in the randomised trial. A total of 903 (n = 445 aged 6–7 years and n = 458 aged 10–11 years) primary school pupils took part. Total Difficulties Score improved in all pupils (6–7 and 10–11 year old pupils) who received the ‘Nourish’ intervention compared with those that did not (adjusted difference in mean = − 0.82; 95% CI -1.46, − 0.17; P < 0.02). No statistically significant difference in Health-Related Quality of Life was observed. The ‘Nourish’ intervention also produced some changes in school-based dietary behaviour, which were most apparent in the 10–11 year old pupils. The ‘Nourish’ intervention also produced improvements in understanding of food labels (adjusted difference in mean = 0.15; 95% CI 0.05, 0.25; P < 0.01) and knowledge of vegetables in season (adjusted difference in mean = 0.29; 95% CI 0.01,0.56; P = 0.04) whilst an increased willingness to try new foods and improved perceived cooking competence was also observed.

Conclusions

Improvements in childhood emotional and behavioural wellbeing, dietary intake, knowledge about food, cooking skills and willingness to try new foods were associated with the ‘Nourish’ whole-school food environment intervention. Exploration of the sustainability and long-term effectiveness of such whole-school food interventions should be conducted.

Trial registration

National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01086-y.

Analysis of whole-school policy changes in Austrian schools

Health Policies with school-wide effects have been shown to improve the health of students and school staff, but in practice, schools struggle with this approach. Ten Austrian schools which had recently adopted new time structure policies were investigated: On the basis of 19 interviews with school staff, we used thematic analysis to identify facilitating and hindering factors for the implementation processes. Furthermore, agency analysis was applied, in which the interviewees’ use of language was interpreted to estimate their perception of their own agency in the context of policy change. We found that in schools where policy changes were perceived as successfully implemented, staff was convinced of the benefits. In these schools, time structures were understood to directly influence learning and teaching processes and staff members showed a strong feeling of agency. On the other hand, schools were confronted with hindering factors similar to those known from the implementation of other health policies. The results are discussed in the light of current implementation practices, and conclusions for practitioners are drawn.

School-level factors associated with teacher connectedness: a multilevel analysis of the structural and relational school determinants of young people's health

Background

Conducting research on the antecedents of teacher connectedness (TC) is key to inform intervention and policy that can leverage the public health potential of teachers for young people’s well-being. As part of the EU-funded Teacher Connectedness Project, this study aims to examine the contribution of a variety of school-level factors (including type of school, school size, student–teacher ratio, students per class and teacher gender).

Methods

Sample consisted of 5335 adolescents aged 11, 13 and 15 years that had participated in the HBSC study in England. Multilevel multinomial regression was used to examine the contributions of sociodemographic and school-level factors to TC.

Results

TC was lower in older adolescents and those from less affluent families, but similar in boys and girls. Regarding school-level factors, it was not the size of the school but the ratio of students per teacher which was significantly associated to TC, with higher student–teacher ratio being significantly associated with lower odds of medium-to-high TC. Some differences between mixed and all-girls schools were also found.

Conclusions

Health promotion strategies targeting student–teacher relationships need to consider how TC changes by age and SES and give attention to school-level factors, in particular the student–teacher ratio.

A population health approach in education to support children's early development: A Critical Interpretive Synthesis

The primary objective of this review is to investigate what is currently known about early childhood education planning, population health models and their relation to children's development. A systematic review using the Critical Interpretive Synthesis method was undertaken, guided by a preliminary research question, "How can a population heath approach be applied to educational planning to support children's early development?" which acted as a compass and guide throughout the process. The initial search yielded 20,122 results, of which 42 were included in the review. Four synthetic constructs emerged (1) Elements of population health models exist within communities and can help improve outcomes for more children, (2) Inter-disciplinary collaboration and partnerships possess unique opportunities to influence children's development, (3) Children's development can be influenced at a variety of levels, and (4) System change requires a range of drivers and supports. Within education, there are several models which are used to improve outcomes for children and families. Although a population health approach to planning does not explicitly exist, the results from this review indicate that it would indeed be plausible to adapt the population health approach to sites and schools, and that doing so would be advantageous for children's development. However, implementing such an approach requires more than desire for change and demands system changes and supports. A protocol for the review was published on the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018098835 on 31st July 2018.

The picture of health: examining school-based health environments through photographs

Health-promoting schools (HPS) is an effective approach to enhance the health and well-being of children and youth, but its measurement remains a challenge considering contextual differences across school environments. The purpose of this study was to qualitatively explore the physical features of the school environment through photographs of schools that had implemented an HPS approach compared with schools that had not. This study used a descriptive approach, wherein physical features of the school environment were distilled through visual images and qualitatively analyzed. School environment data were collected from 18 elementary schools (10 HPS, 8 comparison schools) from a school board in rural Nova Scotia (Canada). Evaluation assistants captured photographs of the physical school environment as part of a broader environment audit. Overarching themes included the promotion, access and availability of opportunities for healthy eating and physical activity, healthy school climate and safety and accessibility of the school. The photographs characterized diverse aspects of the school environment and revealed differences between schools that had implemented an HPS approach compared with schools that had not. There were increased visual cues to support healthy eating, physical activity and mental well-being, and indications of a holistic approach to health among schools that implemented an HPS approach. This research adds to understanding the environmental elements of HPS. The use of photographic data to understand school environments provided an innovative method to explore the physical features of schools that had implemented an HPS approach.

Extending HIV/AIDS-Prevention Efforts in Kenya: Primary Schools as Community-Based Organizations

The question of whether primary schools in Kenya can take on community-based activities beyond their day-to-day functioning, emerged from a larger HIV/AIDS education and prevention program—Primary School Action for Better Health (PSABH). The methodology involved both quantitative and qualitative approaches. The quantitative component was based on 163 schools, which were involved in the larger PSABH program. Qualitative analysis was based on consultative meetings with twenty key informants and follow-up focus-group discussions with representatives from eight schools involved in community-based activities. The results suggest that in this context schools have strong community ties, with most of them willing to take up community-based organization (CBO)-related activities beyond their day-to-day functioning. Schools were more likely to take on CBO-related activities, such as support for orphans, if they had a higher proportion of female teachers, a school sponsor that was involved in the selection of the head teacher, more Parent Teacher Association meetings, and if HIV/AIDS was incorporated into community festivals. A school's involvement was reinforced if it performed well in the Kenya Certificate of Primary Education examination, if the school's head teacher was committed, and if most of the teachers were from the local community. Despite several challenges, the findings point to the need to take schools seriously in their duty as CBOs which can have a positive impact in mitigating not only the effects of HIV/AIDS, but also other community-development activities in ravaged sub-Saharan African countries. The proposed expansion of PSABH further puts Kenyan schools in a stronger position to be involved in their communities through CBO-related activities.

Providing context to the implementation of health promoting schools: A case study

PURPOSE

Issues related to program context are important components of population health interventions and particularly among complex, adaptive initiatives in schools. Health Promoting Schools (HPS) is a global approach to support early development of healthy behaviors among children and youth. The purpose of this study was to explicate the practical and contextual processes that influenced implementation of HPS in schools in Nova Scotia (Canada).

METHODS

Using a case-study approach, data was collected using interviews (n=14) with principals, teachers and parents, observations collected during school visits and document review in five diverse schools.

RESULTS

Case study schools reported a variety of HPS practices and three key themes emerged that provided context to the processes that facilitated their implementation. The results suggest that although school characteristics (theme 1), like staff allocation, physical location and resources, are important, these barriers can be mitigated by building organizational capacity (theme 2) and establishing a supportive school community culture (theme 3).

CONCLUSIONS

The study provided insight to the variability in implementation by describing how contextual barriers were experienced and mitigated by schools. Establishing a broad system to support HPS, with collaboration across health and education sectors, could help to progress adoption, implementation and sustainability of HPS.

The ASCD Healthy School Communities project: formative evaluation results

Purpose

– The purpose of this paper is to report the formative evaluation results from the Association for Supervision and Curriculum Development Healthy School Communities (HSC) pilot project.

Design/methodology/approach

– This study utilized 11 HSC pilot sites in the USA (eight sites) and Canada (three sites). The evaluation question was “What are the levers of change in a school community that allow for the initiation and implementation of best practice and policy for improving school health?” Pre- and post-site visits along with in-depth interviews with school teams, teachers, students, administrators, community stakeholders and other involved individuals, school site report reviews, Healthy School Report Card results and school improvement plans were used for evaluation purposes.

Findings

– This study identified nine levers of change: principal as leader of the HSC efforts; active and engaged leadership; distributive team leadership; effective use of data for continuous school improvement; integration of the HSC process with the school improvement process; ongoing and embedded professional development; authentic and mutually beneficial community collaborations; stakeholder support of the local HSC effort; and creation or modification of school policy related to HSC that increased the likelihood that school improvement via health promotion would be pursued and sustained.

Research limitations/implications

– Owing to the qualitative methods used in this study and the number of schools in the pilot project, the research results may lack generalizability. Therefore, researchers are encouraged to test the proposed evaluation question further.

Practical implications

– This study has implications for schools seeking to create sustainable, systemic integration of health and education for effective health-promoting schools and continuous school improvement.

Originality/value

– This study provides evidence that integration of health and education can become a sustainable and integral part of a school’s culture.

Health promotion in primary and secondary schools in Denmark: time trends and associations with schools' and students' characteristics

Background

Schools are important arenas for interventions among children as health promoting initiatives in childhood is expected to have substantial influence on health and well-being in adulthood. In countries with compulsory school attention, all children could potentially benefit from health promotion at the school level regardless of socioeconomic status or other background factors. The first aim was to elucidate time trends in the number and types of school health promoting activities by describing the number and type of health promoting activities in primary and secondary schools in Denmark. The second aim was to investigate which characteristics of schools and students that are associated with participation in many (≥3) versus few (0–2) health promoting activities during the preceding 2–3 years.

Methods

We used cross-sectional data from the 2006- and 2010-survey of the Health Behaviour in School-aged Children study. The headmasters answered questions about the school’s participation in health promoting activities and about school size, proportion of ethnic minorities, school facilities available for health promoting activities, competing problems and resources at the school and in the neighborhood. Students provided information about their health-related behavior and exposure to bullying which was aggregated to the school level. A total of 74 schools were available for analyses in 2006 and 69 in 2010. We used chi-square test, t-test, and binary logistic regression to analyze time trends and differences between schools engaging in many versus few health promoting activities.

Results

The percentage of schools participating in ≥3 health promoting activities was 63% in 2006 and 61% in 2010. Also the mean number of health promoting activities was similar (3.14 vs. 3.07). The activities most frequently targeted physical activity (73% and 85%) and bullying (78% and 67%). Schools’ participation in anti-smoking activities was significantly higher in 2006 compared with 2010 (46% vs. 29%). None of the investigated variables were associated with schools’ participation in health promoting activities.

Conclusion

In a Danish context, schools’ participation in health promotion was rather stable from 2006 to 2010 and unrelated to the measured characteristics of the schools and their students.

The impact of school policies and practices on students' diets, physical activity levels and body weights: A province-wide practice-based evaluation

OBJECTIVES

To assess what health promotion policies and practices were adopted by schools in Nova Scotia and the extent that these policies and practices affected the diet quality, physical activity (PA) and weight status of students.

METHODS

We developed and administered a 'school practice assessment tool' to assess the presence of 72 different school-based health promotion policies and practices. Surveys were conducted in 2003 and 2011 to assess diet, PA and weight status in approximately 10,000 grade 5 students. We used multilevel regression methods to examine changes in these outcomes across schools with varying levels of health promotion policies and practices between the two time-points.

RESULTS

Between 2003 and 2011 the diet quality of students improved, PA decreased and the prevalence of childhood obesity increased. Although we did not find consistent or significant favourable benefits resulting from higher implementation levels, we did observe fewer negative trends among schools at higher levels of implementation.

CONCLUSION

Our results build on the current gap in knowledge on the impact of Health Promoting Schools (HPS) implementation through population health interventions, but there is a continued need for further evaluation and monitoring of school policies to understand how HPS practices are supporting healthier eating and PA for students.

School health promotion providers' roles in practice and theory: results from a case study

BACKGROUND

Implementation is critical to the success of health promotion (HP) in schools, but little is known about how schools can best be assisted during this process. This article focuses on Austrian HP providers and aspects their roles incorporate.

OBJECTIVE

To investigate the providers' role in the practice of HP implementation and how it differs from its official description. On the basis of these findings, implications are suggested.

METHODS

The data were gathered within the framework of an explorative case study of complex HP interventions. We draw on four interviews with HP organisation staff, five documents from the providers' organisations and seven interviews with school staff from three schools.

RESULTS

In practice, providers took up different responsibilities, e.g., acting as emotional support to school staff and supporting the documentation of projects, guided more by the schools' needs than by the programmes they are helping to implement. Providers focused mostly on the implementation of single activities and did little to emphasize the necessity of organisational change.

POLICY IMPLICATIONS

Our findings suggest that providers' background in health should be complemented by a deeper understanding of the importance of organisational change to further support HP implementation.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Clustering of health-related behaviors, health outcomes and demographics in Dutch adolescents: a cross-sectional study

Background

Recent studies show several health-related behaviors to cluster in adolescents. This has important implications for public health. Interrelated behaviors have been shown to be most effectively targeted by multimodal interventions addressing wider-ranging improvements in lifestyle instead of via separate interventions targeting individual behaviors. However, few previous studies have taken into account a broad, multi-disciplinary range of health-related behaviors and connected these behavioral patterns to health-related outcomes. This paper presents an analysis of the clustering of a broad range of health-related behaviors with relevant demographic factors and several health-related outcomes in adolescents.

Methods

Self-report questionnaire data were collected from a sample of 2,690 Dutch high school adolescents. Behavioral patterns were deducted via Principal Components Analysis. Subsequently a Two-Step Cluster Analysis was used to identify groups of adolescents with similar behavioral patterns and health-related outcomes.

Results

Four distinct behavioral patterns describe the analyzed individual behaviors: 1- risk-prone behavior, 2- bully behavior, 3- problematic screen time use, and 4- sedentary behavior. Subsequent cluster analysis identified four clusters of adolescents. Multi-problem behavior was associated with problematic physical and psychosocial health outcomes, as opposed to those exerting relatively few unhealthy behaviors. These associations were relatively independent of demographics such as ethnicity, gender and socio-economic status.

Conclusions

The results show that health-related behaviors tend to cluster, indicating that specific behavioral patterns underlie individual health behaviors. In addition, specific patterns of health-related behaviors were associated with specific health outcomes and demographic factors. In general, unhealthy behavior on account of multiple health-related behaviors was associated with both poor psychosocial and physical health. These findings have significant meaning for future public health programs, which should be more tailored with use of such knowledge on behavioral clustering via e.g. Transfer Learning.

e-Bug implementation in England

e-Bug is an educational resource for schools, covering the topics of microbes and prudent antibiotic use. A coordinated implementation approach with the e-Bug team, the Department of Health, and the Department for Children, Schools and Families resulted in the dissemination of 20,500 Junior and Senior e-Bug packs to all maintained schools in England in 2010.

Young park users' attitudes and behaviour to sun protection

The increase in skin cancer prevalence globally has prompted a range of health promotion sun safety initiatives. An area where evidence has been lacking is on the long-term impact of some of these initiatives on the attitudes and sun protection behaviour of young adults and of the sun protection measures used by people using city parks. This article disseminates a study that examined the knowledge, attitude and behaviour of 18- to 28-year-old Caucasian park users. An interview questionnaire was used with behaviour validation incorporated to corroborate the results and reduce recall bias. A cross comparison of answers and placement into pre-coded responses were made at regular intervals to ensure consistency of data collection. Knowledge of risks associated with sun exposure and knowledge of sun protection methods was high. The most common sources of knowledge on skin cancer prevention were parents and family, followed by television, then magazines and newspapers. Surprisingly, the citing of school sun safety health promotion initiatives as a source of knowledge was low. The vast majority of females and males felt that a suntan had aesthetic qualities and made them look more attractive and healthy. Only a small number of the participants' sun protection behaviour in the park corresponded with their reported normal sun protection behaviour. Males in this study use sunscreen less than females. Females also used sunscreen with a higher sun protection factor. Seeking a tan is intentional behaviour undertaken by the majority of the participants, although females were more likely to seek a tan in comparison to males. The majority of participants had experienced sunburn in the summer period with some reporting severe sunburn. Recommendations are made for a gender specific health promotion approach, which targets familial education with a supportive environment in the school or public domain.

Health needs: policy plan and school practice in Greece

Purpose

The purpose of this paper is to explore the concept of health‐related needs on a policy design and curriculum enactment basis in terms of the national school health education curriculum in Greek secondary education.

Design/methodology/approach

A single case study, using an ethnographic approach, was conducted in Greece, seeking to understand the continuum from policy design to curriculum enactment in respect of health‐related needs. Three sources of data were used to meet this goal: policy texts, observation, and interviews. Multilevel sampling was employed to select one secondary school as a site for “good practice”. Grounded theory coding, thematic analysis and critical discourse analysis identified themes associated with the idea of health‐related through the corpus of data.

Findings

On a policy plan level the concept of health‐related needs was coupled with and reduced to a predetermined list of health‐related subjects; and the list of health‐related topics had not been updated for long and was characterised by a rather biomedical orientation. On a school practice level the stage of needs assessment was not applied, the list of health‐related subjects advocated in the policy plan was used on a proactive, normative and top down basis, and the students' felt needs tended to be disregarded.

Originality/value

This study followed up the continuum from policy design to school practice regarding the concept and practice of health needs, highlighting the possibilities and the problems from both perspectives.

Implementing School Health Promotion in Austria

A pilot training course on school health promotion in Austria focused on supporting teachers and school heads during the implementation of the health-promoting school (HPS) concept. The participants talked about their experiences during the implementation phase in focus groups held in a feedback seminar at the end of the training course. The focus groups were analyzed by using an inductive approach. A coding method for thematic analysis was applied. Compatibility of the training course with the school setting was examined and supporting and hindering structures and processes pertaining to the schools and the training course are described. The results can be displayed in a model showing connections between the themes. Internal and external collaboration structures were identified as central aspects in the implementation phase. Particularly collaboration within the faculty is shown to be of importance when implementing the HPS approach. Voluntary cooperation especially of teachers, which is often connected with work in their spare time, is another aspect influencing the sustainability and therefore also the compatibility of the training course with the school setting. For future designs of teacher training courses in health promotion, the aspects of collaboration, teamwork, and collective commitment have to be taken into consideration.

The effects of individual factors and school environment on mental health and prejudiced attitudes among Norwegian adolescents

INTRODUCTION

The aim was to examine the prevalence of mental health difficulties and prejudices toward mental illness among adolescents, and to analyze possible school and school class effects on these issues.

METHODS

The sample comprised 4,046 pupils (16-19 years) in 257 school classes from 45 Norwegian upper secondary schools. The estimated response rate among the pupils was about 96%. Self-reported mental health difficulties were measured with a four-item scale that covered emotional and behavioral difficulties. Prejudiced attitudes toward mental illness were assessed using a nine-item scale. Multilevel regression analysis was used to estimate the contribution of factors at the individual level, and at the school and class levels.

RESULTS

Most of the variance in self-reported mental health difficulties and prejudices was accounted for by individual level factors (92-94%). However, there were statistically significant school and class level effects (P < 0.01), confounded by socioeconomic factors. Mental health difficulties were commonly reported, more often by females than males (P < 0.01). Difficulties with emotions and attention were the two main problem areas, with definite to severe difficulties being reported by 19 and 21% of the females, and by 9 and 16% of the males, respectively. Prejudices were reported more often by males than females (P < 0.01). Both self-reported mental health difficulties and prejudiced attitudes were related to educational program, living situation, and parental education (P < 0.01).

CONCLUSION

The relatively high prevalences of mental health difficulties and prejudiced attitudes toward mental illness among adolescents indicate a need for effective mental health intervention programs. Targeted intervention strategies should be considered when there is evidence of a high number of risk factors in schools and school classes. Furthermore, the gender differences found in self-reported mental health difficulties and prejudices suggest a need for gender-differentiated programs.

Practices and representations of health education among primary school teachers

AIMS

School is one of the key settings for health education (HE). The objectives of this study are to assess primary school teachers' self-reported teaching practices in HE and to describe their representation concerning their role in HE.

METHODS

A quantitative study was conducted on a sample of primary school teachers (n = 626) in two French regions in order to analyze their practices and representations in HE. A hierarchical clustering dendogram was performed on questions exploring representations of HE. Multiple linear regression analysis helped explain the motivation and self-perceived competency score.

RESULTS

Three quarters of the teachers declare they work in HE. Only one third of them declare they work in a comprehensive HE perspective. The HE approach is often considered in terms of specific unique curriculum intervention. Two thirds of the teachers say they work alone in HE, the other third associate other partners and choose mainly school health services. Parents are rarely (12%) involved in HE initiatives. It is essentially the practice of HE, teacher training and teachers' representation of HE that condition their motivation to develop HE.

CONCLUSIONS

Teachers can take different approaches to HE. Teachers' representation of HE plays an important role in the development of HE activities: some teachers consider that HE is the mission of the health professionals and the parents. Our expectations of teacher involvement should be realistic, should take into account the representations of their role, the difficulties they encounter, and should be sustained by specific training.

Evaluación de las Escuelas Promotoras de Salud en Asturias (España)

n: Objetivo: Evaluar la situación de las escuelas en relación a la Promoción de la Salud, sus fortalezas y debilidades, a través de la incorporación de los principios de la Red Europea de Escuelas Promotoras de Salud y de las opiniones de alumnado y profesorado. Metodología: La población de estudio fueron 29 centros educativos. Se realizó una visita a cada centro y se recogió información por observación directa y entrevistas a equipo directivo, persona coordinadora del proyecto de salud y alumnado. Los criterios evaluados fueron: experiencia, compromiso, implicación del profesorado, metodología con alumnado, participación comunitaria, mejora del entorno, democracia y equidad, y otras acciones promotoras de salud. Cada criterio se valoró con una o varias variables. A cada criterio, se le dio 1 punto, de manera que cada centro podía obtener un total de 8 puntos. Juntos con éstas se recogieron otras variables cualitativas en relación a las fortalezas y debilidades de los centros en Promoción de la Salud. Resultados: La puntuación media de los centros fue 5,19 (DE: 1,16). Mayoritariamente, los centros tenían experiencia previa, incluía la Promoción en la Programación General Anual y en el Proyecto Educativo, y contaban con profesorado implicado, organizado y formado. Aproximadamente la mitad tenía una estética agradable y realizaba incorporación curricular, acciones de coeducación, de mejora del entorno, de alimentación saludable y actividades con comunidad. La participación del alumnado, de las familias y el uso organizado de espacios se dio en un porcentaje minoritario de centros. Conclusiones: Se constató un esfuerzo importante por incorporar la Promoción de la Salud, pero numerosas dificultades para ello. La principal limitación tiene que ver con la voluntariedad de estas acciones y la ausencia de políticas públicas para transformar los centros educativos. Destacar la aportación novedosa de esta investigación, en relación a la creación de un indicador global que permite evaluar la incorporación de la Promoción de la Salud en las escuelas utilizando los criterios de la Red Europea de Escuelas Promotoras de Salud. (Global Health Promotion, 2009; 16(3): pp. 96—106)

Assessment of a national network: the case of the French teacher training colleges' health education network

The French teacher training colleges' health education (HE) network was set up in 2005 to encourage the inclusion of HE in courses for primary and secondary school teachers. A systematic process of monitoring the activity and the impact of this initiative was implemented. This analysis was systematically compared with the perceptions of teaching staff involved in the network. This paper assesses the network after 2 years using documents produced and interviews with 24 coordinators. Twenty-nine teacher training colleges out of a total of 31 are involved in the network. The network has helped to create links between teacher training colleges, extend HE training and encourage partnerships with other public health organizations. By 2007, HE was included in courses offered by 19 teacher training colleges as opposed to only 3 in 2005. This study not only showed the positive impact of the network but also revealed issues in its management and presented new challenges to ensure the effectiveness of the network. The network has succeeded in attracting and training trainers who were already providing or were interested in HE. Reaching other trainers who are not familiar with HE remains a challenge for the future.

Depressive symptoms in adolescent pupils are heavily influenced by the school they go to. A study of 10th grade pupils in Oslo, Norway

BACKGROUND

A school is generally acknowledged to be a key setting for promoting pupils' health and well-being.

METHODS

Data from a cross-sectional questionnaire study conducted with all 10th grade pupils in 46 public schools. Depressive symptoms was defined by a positive score on Hopkin's Symptom Check List-10 (HSCL-10). Two composite variables expressing risk were established: (i) presence of negative factors (PNF), consisting of self-reported pressure to succeed, sexual violation, and exposure to bullying and violence; and (ii) absence of positive factors (APF), comprising respondents' self-reported physical activity, educational aspirations, and family's valuing their opinions.

RESULTS

Out of 7505 pupils, complete data were obtained for 6207. The prevalence of symptoms of depression varied greatly among different schools (boys, from 0 to 19%; girls, from 3.3 to 39%). The PNF varied from 12.3 to 45.5% for boys, and from 4.2 to 38.8% for girls. Corresponding figures for APF were 2.4-23.1% for boys and 4.3-37.5% for girls. Among boys, we found significant associations between PNF and symptoms of depression, odds ratio (95% CI) 4.5 (3.5-5.8), and between APF and depressive symptoms, 3.1 (2.3-4.1). For girls, corresponding odds ratios were 3.5 (2.9-4.2) and 2.1 (1.7-2.6), respectively.

CONCLUSIONS

The proportion of pupils with depressive symptoms varies greatly among Oslo public schools. This variation is associated with features of the pupils' social context.

"An integral part of the children's education": placing sun protection in Auckland primary schools

Links between ozone depletion, sun exposure and the incidence of melanoma in later life have focussed public health attention on risk management, including attempts to curtail children's exposure to sunlight. Schools are potentially valuable sites in sun protection efforts, as they may combine behavioural messages with protective environments. In this paper, we outline the sun-related attitudes and policies of a random sample of 20 Auckland primary schools, and situate them within the framework of the new public health. We observe that while the state requires schools to provide students with a safe environment, there is no explicit guidance on what this means in terms of sun protection. Accordingly, schools' responses vary according to the perceptions and priorities of individual principals. We conclude that while school spaces are being transformed through the public health focus on the risks of UV exposure, the neoliberal educational landscape in New Zealand appears ambiguous in its support for health promotion.

A cross-national comparison of school drug policies in Washington State, United States, and Victoria, Australia

Using mail survey data collected from primary and secondary school administrators in Washington State, United States, and in Victoria, Australia, this study compared aspects of the school drug policy environment in the 2 states. Documented substance-use policies were prevalent in Washington and Victoria but less prevalent.in primary schools, especially in Victoria. Victorian school policy-setting processes were significantly more likely to involve teachers, parents, and students than processes in Washington schools. Consistent with expectations based on their respective national drug policy frameworks, school drug policies in Washington schools were more oriented toward total abstinence and more frequently enforced with harsh punishment (such as expulsion or calling law enforcement), whereas policies in Victorian schools were more reflective of harm-minimization principles. Within both states, however, schools more regularly used harsh punishment and remediation consequences for alcohol and illicit-drug violations compared to tobacco policy violations, which were treated more leniently.

The Gatehouse Project: can a multilevel school intervention affect emotional wellbeing and health risk behaviours?

STUDY OBJECTIVE

The aim of this study was to determine the effect of a multilevel school based intervention on adolescents' emotional wellbeing and health risk behaviours.

DESIGN

School based cluster randomised controlled trial. Students were surveyed using laptop computers, twice in the first year of intervention and annually thereafter for a further two years.

SETTING

Secondary schools.

PARTICIPANTS

2678 year 8 students (74%) participated in the first wave of data collection. Attrition across the waves was less than 3%, 8%, and 10% respectively with no differential response rate between intervention and control groups at the subsequent waves (98% v 96%; 92% v 92%, and 90% v 89% respectively).

MAIN RESULTS

A comparatively consistent 3% to 5% risk difference was found between intervention and control students for any drinking, any and regular smoking, and friends' alcohol and tobacco use across the three waves of follow up. The largest effect was a reduction in the reporting of regular smoking by those in the intervention group (OR 0.57, 0.62, and 0.72 at waves 2, 3, and 4 respectively). There was no significant effect of the intervention on depressive symptoms, and social and school relationships.

CONCLUSIONS

While further research is required to determine fully the processes of change, this study shows that a focus on general cognitive skills and positive changes to the social environment of the school can have a substantial impact on important health risk behaviours.

Juvenile and early adulthood smoking and adult educational achievements--a 31-year follow-up of the Northern Finland 1966 Birth Cohort

AIMS

To investigate the association between juvenile and early adult cigarette smoking and educational achievements up to the age of 31 years.

METHODS

As a part of the follow-up of the North Finland 1966 Birth Cohort (n = 10542) from 1966 to 1997, smoking was assessed at the ages of 14 and 31 by postal questionnaires. The highest level of educational attainment was obtained from the National Education Registry of Statistics Finland up to the age of 31 years.

RESULTS

Adult smoking (at age 31) and prolonged smoking (at ages 14 and 31) were both associated with an approximately two- to sixfold, adjusted odds for educational underachievement. Smoking only at age 14 showed none of these associations.

CONCLUSION

These results are unlikely to be causal, but may be explained by other characteristics associated with smoking such as personality or lifestyle factors, as well as the effect of knowledge related to smoking gained during higher education.

Building capacity for system-level change in schools: lessons from the Gatehouse Project

The Gatehouse Project is an innovative, comprehensive approach to mental health promotion in secondary schools. It sets out to promote student engagement and school connectedness as the way to improve emotional well-being and learning outcomes. The key elements of the whole-school intervention are the establishment and support of a school-based adolescent health team; the identification of risk and protective factors in each school's social and leaning environment from student surveys; and, through the use of these data, the identification and implementation of effective strategies to address these issues. The project evaluation used a cluster-randomized controlled trial design involving 26 schools with initial results demonstrating considerable success in reducing smoking rates among Year 8 children. This article describes and accounts for how system-level changes have been made in schools through a process of capacity building. This encourages teachers, parents, and students to view the core business of education differently.