Finding a place for health in the schooling process: a challenge for education.

It is common in schools for health and education goals to be seen as agendas that are in competition. However schools do attempt to find time in crowded curriculums to cover health issues as part of their responsibility towards advancing the health of their students. A qualitative approach was used in this study to explore perceived outcomes of a Health Promoting School intervention project. The project schools targeted for in-depth study were purposefully sampled to include diversity based on location, level, system and specific health activities. The results showed that the schools involved were moving beyond oppositional constructions of health and education towards approaching health as an element of effective schooling. It is concluded that in any effective health promotion activity in schools, the agenda needs to be driven primarily by an education sector that has demonstrated it can embrace holistic approaches to health, with the health sector acting as partner and facilitator.

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   We should be doing more in the health area but the curriculum is already
   overcrowded ... The development of literacy and numeracy skills must be
   priorities, and time and professional development opportunities must be
   found to continue progress in these area ... And we must develop
   initiatives to improve student welfare and continue to improve teaching and
   learning throughout the school ... How do we find the time for health?
   (Primary school principal)

Health in schools: An acknowledged area of concern

As part of a school review and forward planning process, the primary school principal above verbalised a range of demands that his school was facing, including learning outcomes, teaching, welfare and health. There are two key issues in this extract. First, the quote reflects a common discourse in schools that there is trade-off between health and education outcomes--you invest in one at the expense of the other. However recent work in comprehensive health promotion in schools has begun to call into question this kind of dichotomy. Although the research reveals differences in health and education agendas, it also points to a good deal of overlap and synergy between the agendas of the two sectors (Kolbe, 1993; Samdal, Nutbeam, Wold, & Kannas, 1998; Symons, Cincelli, James, & Groff, 1997; World Bank, 1993; World Health Organisation, 1996). Second, traditionally the health and education sectors have taken quite different approaches to promoting health. The health sector has tended to focus on single issues (e.g. nutrition, STDs, drugs) and conceive of schools as convenient settings for reaching a particular target group to influence behaviours (St Leger, 1992; St Leger & Nutbeam, 2000a). The education sector, on the other hand, has understood health more as one of a number of key learning areas and, in dealing with health, has focused on knowledge, understanding and cognitive skills. In practice, the school contribution to health is seen by schools as finding time in a crowded curriculum to develop knowledge and skills that will promote better learning and healthier approaches. In this way, schools have accepted their responsibility to respond to wider community health concerns but, like the principal in the above vignette, schools are aware of their limitations.

Extending health education beyond curriculum content

Health, as part of schooling, has been promoted since 1910. From that time, the focus of school health has gone through three phases:

1 health instruction (1910 to mid-1950s): where students were instructed to be fit (called physical culture), not use alcohol (temperance instruction), and have `pure thoughts'--the first foray into moral education;

2 health education (mid-1950s to 1980s): where emerging health knowledge was incorporated into the curriculum (particularly in the fields of nutrition and biological sexuality), and focused on classroom-based education with few formal links to the health sector; and

3 health promotion (early 1980s until the present): where health-related interventions in schools are incorporating the curriculum and include school-based policies and links to the local community. (St Leger, 1991)

The basis for an extended view of school health in this third phase can be found in the concept of the Health Promoting School (HPS). The HPS movement, with its origins in the World Health Organisation's (WHO) Ottawa Charter, has become prominent in national and international efforts over the past decade to improve the health of students. Rather than focusing on individual behavioural change, the HPS concept was developed from a socio-ecological perspective in which health is considered to emerge from a range of individual, social and political considerations (Nutbeam, 1992; WHO, 1986). The HPS framework has been embraced by the European Community, and closely resembles the Coordinated School Health initiatives (CSH) in the United States of America (Allensworth 1995; Tones 1996).

Essentially the HPS--while acknowledging the importance of the curriculum--moves beyond the classroom in order to identify and provide a framework for working with the various components of schooling that impact on health opportunities for students. Attention is directed not only towards the curriculum, but also towards physical and social environments; school-based health policies; links with health services; and school partnerships with various sections of the community. The HPS framework groups the range of school operations and characteristics into three areas, as illustrated in Figure 1.

Figure 1 The Health Promoting Schools framework (adapted from WHO 1998)

* Curriculum, teaching and learning--What the school teaches in relation to health and health skills, and the nature of the teaching and learning processes that are part of all classrooms.

* School organisation, ethos and environment--The school's values and ethos, its organisation, structures and policies, and its social and physical environments.

* Community links and partnerships--Links between schools and their communities, particularly their relationships with parents and families, and their linkages with community agencies and services.

Promoted by the WHO, the HPS framework has gained credibility over the last decade, with many countries, including Australia, working on HPS programs to support schools and their communities in more holistic health actions (Ridge, Marshall, Northfield, Maher, St Leger, Sheehan, & Elisha, 2000; WHO, 1996). There is an emerging evidence-based case for supporting HPS (Lister-Sharp, Chapman, Stewart-Brown, & Sowden, 1999; St Leger & Nutbeam, 2000b). The impact of school health promotion initiatives on the health of students is positive and considered cost effective (Rothman, Ehreth, Palmer, Collins, Reblando, & Luce, 1994). Additionally the links between good health and favourable education outcomes are now clearly established in the literature (Brellochs 1995; National Health and Medical Research Council, 1996; Samdal et al., 1998; Symons et al., 1997; WHO, 1996).

Given the emerging evidence of the need for a multifaceted approach to health in schools, the Faculty of Health and Behavioural Sciences at Deakin University and the Victorian Department of Education, Employment and Training (DEET) implemented a project (referred to as `the Project' in this paper) to establish the HPS framework in Victoria as the basis for schools' approaches to comprehensive health promotion. VicHealth funded the HPS Project from 1997 until late 2000. In the Project, schools were expected to set priorities for action, and plan and then implement health promotion projects in their schools over a one-year period. In order to encourage a holistic approach, the Project provided a range of resources including a tool for staff to audit what was already happening in their schools in terms of health practices and policies; professional development for teachers; funding for teacher release time; assistance in strategic planning; and various support resources such as regular newsletters and a guidebook (Ridge et al., 2000). A diverse range of 100 schools were chosen for inclusion in the Project, based on criteria such as location (urban and rural schools included); past school health initiatives; level (primary and secondary); and system (government, Catholic and independent). Formal evaluation and feedback was also provided to schools. The current paper draws predominately on qualitative data from the evaluation phase of the Project to explore the role of health in contemporary Victorian education. As discussed in this paper, some schools in Victoria are moving beyond more limited and polarised constructions of health and education into an era where the concerns of health are being conceptualised as consistent with contemporary approaches to good schooling. As a consequence, certain opportunities and ways forward are presenting themselves.

Methodology

Given the limited timeframe of the HPS Project, the developmental nature of the Project, the foci of schools and evidence from evaluations of major international school health intervention programs, it was clear from the outset that the diverse activities under the Project's umbrella would not clearly change the behaviour of students, or perhaps even improve their health within the evaluation timeframe. Even if such changes were noted, it would have been difficult to attribute them to the Project given that it operated in complex contexts, where interventions were often multifaceted and operating alongside other school health initiatives (e.g. Turning the Tide--a Victorian drug education program, sun protection campaigns, tobacco reduction programs). Instead of focusing on behavioural and health outcomes, it was decided by the research team that the evaluation needed to focus on processes, meanings and perceptions of outcomes within an educational setting.

The quantitative methods used in the HPS evaluation are described in detail elsewhere in the literature (Ridge et al., 2000; St Leger, Maher, Ridge, Marshall, Sheehan, & Gibbons, in press). Briefly these quantitative methods involved a pre- and post-audit to determine what was happening in all of the 100 schools in terms of health practices and policies under the main headings of the HPS framework before and after the intervention. The audit also investigated perceived outcomes from the Project. The qualitative arm of the evaluation--with a focus on processes, perceptions and meanings--provided the bulk of the data underpinning this paper. A case study design was incorporated into the evaluation since it can capture real-life complexities of processes and outcomes using both qualitative and quantitative data, and the literature suggests that such an approach is optimal in HPS evaluation work (Inchley, Curry, & Young, 2000; Lister-Sharp et al., 1999; WHO, 1996). In late 1999, 13 out of the 100 schools involved were purposefully sampled for case study. These schools were invited for interviews on the basis of a range of criteria, including level (primary, secondary, P-12); location (urban, regional); system (government, Catholic, independent); and kinds of HPS activities that were underway. Key questions asked in the interviews were: How did the school become involved in the HPS Project and who worked in the Project? How did the HPS Project find a focus, and how was the Project implemented and kept on the school agenda? What unique contexts were involved? What were the outcomes, and to what extent would changes have occurred without the Project? What kinds of partnerships were encouraged by the Project, if any? What was the comprehension of the HPS concept?

Two researchers attended each school and interviewed between one and four school community members. Where more than one person was interviewed at a school, interviews were conducted with pairs of interviewees in order to encourage discussion about answers. Although the interviews tended to be informal and directed by the conversation, a detailed interview schedule was used to ensure that all questions were adequately covered. All interviews lasted between 90 and 120 minutes. Financial support was made available for teachers and other school personnel to be released for interview. All of the interviews were recorded and fully transcribed by a professional transcriber. Analysis of secondary documentation already collected from the schools (e.g. HPS school's register, school charters, newsletters, strategic plans) was also undertaken in order to identify the extent of HPS-related activities undertaken in schools, as well as to identify major patterns and themes in the implementation of projects. Case studies were written up for each of the schools. Schools were sent drafts of the case studies to review, and each school was asked to approve the final version for inclusion in a handbook entitled Health Promoting Schools in action: A guide for schools.

In addition, one urban and one rural focus group were conducted shortly after the case study interviews were completed. All 87 schools that had not been involved in case study interviews were invited to attend these focus groups. The two focus groups were timed to permit the feeding in of themes emerging from the earlier interviews. Focus groups further investigated resources used in the HPS project, the role of other projects (e.g. Turning the Tide), sustainability and outcomes. The urban focus group included participants from all four urban DEET regions. The rural focus group included representatives from DEET regions not included in the case study interviews.

In analytical sessions that were conducted after all of the focus group interviews, assertions were put forward by the authors and debated. The assertions that could be defended were then used in conjunction with the transcripts and case study drafts to develop the analysis being conducted by the first author. General themes emerging from the case study and focus group data were recorded manually. Other researchers in the team then critiqued the draft analysis. Feedback from teachers was incorporated into the final analysis.

Results and discussion

The qualitative evaluation of the Project showed that schools involved in interviews were prepared to review and contest some traditional school health and education assumptions of practice. The key assumptions challenged are identified and discussed below.

Reconceptualising school health

School A

   `We were a growing school ... children outside were becoming involved in
   more conflict situations, they didn't have a great deal to do outside.'

   School A is a young primary school serving a number of developing housing
   estates in Melbourne's west. The school has always had a serious commitment
   to health, yet teachers were noticing more conflict among students in the
   playground. The initial focus for the HPS effort was to encourage student
   involvement in more useful outdoor activities. An equipment borrowing
   system was set up which promoted student responsibility in equipment
   distribution, use and return. This HPS effort was expanded after
   observations of the playground. These observations suggested that it was
   also important for teachers to take up issues emerging in the playground
   and spend some regular classroom time having students reflect on issues.
   Hence the `Take Five' program was established. Here childrens' experiences
   were used to raise issues such as bullying, relationships, co-operation and
   respect for differences. More recently, interest in health has expanded to
   the importance of staff welfare. A staff fitness competition was
   implemented to help encourage this new focus. The school is currently
   considering peer mediation and parent involvement in HPS efforts.

   `The HPS project ... gave us a target ... a framework to set out our goals
   ... something to aim for.'

For a number of schools that participated in the case study interviews and focus groups, the conceptualisation of school health moved from a perception of health as a content area of the curriculum towards a perception of health as being shaped by a wide range of school components including student and parental involvement in decision making, physical environments, sense of belonging, adequacy of community services and professional development. This shift in health understanding in schools was clearly anticipated by the authors from the outset, given the equal emphasis on the three components of health in the HPS framework (see Figure 1). The audit of school health activities conducted by individual schools at the beginning of the HPS project in early 1997 indicated that much health promotion work was occurring in schools at a variety of levels, even if it was not labelled as such (Ridge et al., 2000). According to schools that participated in the qualitative interviews, the audit turned out to be a valuable educative exercise in that it revealed the different components of school life that can shape health, what the school was doing, and what still needed to be done.

The main directions each of the case study schools took in the Project are summarised in Table 1. From the table, it is clear that the case study schools focused on a range of components shaping school health that went well beyond the curriculum. Practices and policies were prominent around staff health and welfare, positive school relationships, and student mental health, particularly bullying.

A number of the schools promoted health agendas through an educational focus. The development of student welfare policies and practices, and improvement of teaching and learning approaches were seen by schools as important steps in promoting health at the school level (Ridge et al., 2000). Interviewees attributed changes in students, their schools and associated community links to school involvement in the Project (see Table 2). The reported school achievements of the Project included greater awareness of, and skills in: health promotion; better learning outcomes; better student participation; increased perceptions of student and teacher wellbeing; better co-ordinated and more comprehensive health promotion approaches; improved social environments; and better links with the community. Many of these kinds of changes are really about better, more effective schools. Confirming these results, in the post-project audit 93 per cent of the 100 project schools indicated that they felt they were `better equipped to implement education system policies and requirements concerning student welfare', and 69 per cent indicated that they felt their teaching was more student-centred (Ridge et al., 2000).

Building community links

School B

   School B is a large primary school with over 800 children in a growing
   western suburb of Melbourne. There is a tradition of community
   participation. The primary focus for the school's HPS effort was to build a
   beautiful `passive garden' area where students, staff and parents could go
   for quiet activities. A committee was formed including interested students,
   staff, parents and a community health officer. An implementation plan was
   developed, including a student competition to design the garden. An audit
   of parent skills to build the garden was undertaken. Newsletters kept the
   community informed, working bees were programmed and local businesses were
   drawn in (some even donated materials). In describing the project, one
   teacher said it `took on a life of its own'. The result was a garden with a
   paved area, amphitheatre, sails, gazebo, waterfall, sandpit, tables, chairs
   and a mural. The HPS activities of the school were expanded to include
   policies in the area of staff wellbeing, drugs and sexuality, all with an
   appreciation of the importance of community links.

Analysis of the delivery of school health initiatives in the Project schools detected some shift away from the reliance on school staff time and expertise and a focus on the curriculum to a greater involvement of community agencies and partnerships with the health sector (Ridge et al., 2000). This happened because the Project broadened awareness of the wider community/agencies/services available to schools, and a range of relationships and partnerships were initiated or enhanced in project schools. There was something about the nature of tackling health issues comprehensively that helped schools to overcome some traditional barriers between them and their communities. The evaluation showed a number of productive relationships emerged because of the HPS project. It was clear from the qualitative analysis that schools and their communities had a better understanding of how each other functioned and what opportunities existed for useful links that enriched the core business of each partner. These findings reinforce earlier evaluations in Europe, North America and Australia (Brellochs, 1995; Cohen, 1995; Kalnins, Ballantyne, Quataro, Love, Stuffs, & Pollack, 1994; Went, 1992).

Partnerships took on a number of forms, including closer contact with parents, working with outside agencies, referrals, ongoing telephone contact with professionals, special community events, training and conferences. Despite these encouraging signs, it needs to be acknowledged that the Project only contributed to the limited formation of partnerships. It was frequently difficult for schools to establish and maintain meaningful relationships with sections of the community for a range of reasons. For instance, some schools were better served by relevant agencies than others; some projects (e.g. outdoor activities program) were not so reliant on partnerships; some services were too expensive for schools; and cultural and social class differences could make it difficult to engage parents in school issues (e.g. some working-class parents only have experiences of schools as alien and punishing from their own childhoods, and Vietnamese parents might believe that they do not have the authority to participate with teachers in their child's learning). By giving as much emphasis to linkages as it does to the curriculum and ethos/environment, the HPS framework currently works to highlight the potential for community linkages and legitimise the resources teachers invest in developing these, rather than reflect the actual investment in community links.

   It was good to have the three areas because then you could ... you just
   make sure that you bulk them all up ... you're not `lop-siding'. I mean, we
   just wanted to have a balance to it all. I used to just check that we
   haven't left one of them out and the community was just as important in
   that as the other two. (teacher, government primary school, country)

Redefining the outcomes of school health

The Project supported a shift from an emphasis on school health outcomes for students that were concerned largely with knowledge and skills acquisition relevant to societal health issues towards concepts of health literacy (1), student autonomy and action competence. (2) In the Project, schools did come to recognise that tackling health and social issues helped in maximising learning outcomes. For instance, the Health Promoting School framework assisted some schools to move further away from hierarchical school structures towards more collaborative, student-centred and socially aware ways of working.

School C

   School C is a medium sized Catholic primary school in a south-eastern
   suburb of Melbourne. This school placed a high priority on student welfare.
   As part of its Health Promoting School approach, the school implemented
   initiatives designed to positively affirm students and provide
   opportunities for them to take on greater responsibilities in the school.
   Along with ongoing support of the Student Representative Council,
   initiatives included peer mediation and regular affirmations via `Pupil of
   the Week'. They also used a system of `Behaviour Reports' that encouraged
   students involved in an incident to answer a list of questions designed to
   help them reflect on the particular incident, their behaviour, the
   consequences and their own responsibilities in rectifying the situation.
   The staff interviewed about the strategy were very positive.

   `When given the opportunities, kids rise to the occasion. They don't let
   you down ... [we need to] take the risk to let them [students] take
   responsibility'.

   `Having to take responsibility for rectifying that situation means there is
   a thought process going on that otherwise wouldn't have occurred.'

Developing local ownership of school health-related initiatives

School D

   School D is a secondary college in a town in Victoria's south-east where
   there has been considerable downsizing by key companies over the past 10
   years. Added to this, recent workplace changes including amalgamations have
   resulted in a good deal of change including an influx of students who
   placed less value on academic education than previous cohorts. Given raised
   anxieties, the focus for the HPS effort became staff wellbeing and their
   participation in decision making and organizational aspects of the college.
   Staff wellbeing and participation were built into the formal college
   planning processes including the school charter. Links have been made with
   Community Services in the area which offers lifestyle programs to staff. An
   inhouse professional development program has also been established,
   covering topics such as health, wellbeing and approaches to teaching. A
   staff services committee keeps staff welfare issues on the agenda and
   maintains communication with the college administration. The committee
   monitors progress with the charter priority and analyses the results of
   staff surveys.

The Project evaluation has illustrated how ownership of the school contribution to health can shift from externally developed programs and curriculum descriptions towards school-based development of initiatives, policies and procedures. The HPS projects in schools tended to become located around issues that were pertinent to schools and already taking up time (e.g. violence, staff welfare). Indeed over 90 per cent of project schools in the post-intervention audit indicated that the HPS project linked in with other projects already occurring within the school and that it provided impetus and momentum to extend on previous and current work (Ridge et al., 2000). There was a sense that being involved in the HPS project helped people to reconceptualise and reorganise their activities to find better ways forward and to add value to their work. Additionally many interviewees considered that the HPS project provided an opportunity to bring specific projects together under the one umbrella for a more unified and co-ordinated approach to health promotion.

The qualitative analysis suggested that those who had a strong sense of what their school was trying to achieve in the long term, and who understood how different projects could be co-ordinated to increase effectiveness and save time, were best able to adapt the multitude of short-term projects (with varying agendas) that come into their schools to their own benefit and use the HPS framework to their best advantage.

   Well, we know what we want and where we are going. I think ... we're aware
   that things open and shut and open and shut, so if there's an opportunity
   we'll take it and blend it into our purposes, so in a sense we've moved
   along fairly stoically and things pop in really, so we haven't been rocked
   and rolled and done over ... We can make things fit our model, we are good
   at that. (teacher, government primary school, country)

Greater ownership of school influence on health is illustrated in the way that the issue of staff health and wellbeing was taken up by the schools. At the time that the HPS project was implemented, teachers were much more used to thinking about the welfare of students. Teacher welfare appeared to be an issue that the employing authorities were not adequately pursuing. A majority of the 100 schools (66) nominated teacher health and wellbeing for inclusion in the professional development offered as part of the HPS project, making it the most popular topic chosen. The interviews revealed high levels of concern about a perceived deterioration in teacher health associated with ageing staff and workplace changes, including increased uncertainty, demands and time pressures. Clearly teacher wellbeing was an issue whose time had come. The shift here involved teachers giving themselves permission to acknowledge that their needs were legitimate, and that they had a right to feel well. The approaches adopted to promote staff wellbeing were diverse, taking in all aspects of the HPS framework. Approaches included professional development; time set aside for debriefing and socialising; committees set up to develop policies; relaxation techniques; review of curriculum; and the use of outside services (e.g. facilitation, counselling and conflict resolution).

Conclusions

The HPS framework has shown itself to be a very flexible framework in the Project schools involved in qualitative interviews. In practice, the HPS project has operated in the schools at a number of levels. It has helped to broaden health from curriculum content to a more comprehensive understanding of, and approach to, the elements of school life that affect health; increased the awareness of the community in which schools are situated and legitimised the allocation of resources to develop links that are practical; strategically brought health more within the core business of schools, namely, educational outcomes and student welfare; increased ownership of what schools can do to increase health; and helped shift health more into a dynamic political domain to increase student knowledge, skills and empowerment.

The current study found that health perspectives will be incorporated into schools to the extent that they fit with the nature of schooling and the demands being placed on schools and teachers. Schools that are successful are clear about what they themselves stand for, what their critical issues are, and the directions they wish to take. They then shape the health perspectives to achieve their own agendas.

While schools feel under pressure to deal with a range of societal issues (e.g. violence, drugs, suicide, mental health), there are real constraints on what schools can do. Schools cannot remedy all social ills and health problems, and it is difficult for schools to sustain projects that ultimately do not fit with their core business of education. The Project evaluation results suggest that we need to move away from funding discrete, individual health projects around `illth' topics (e.g. drug use, injury, sedentary behaviour, poor diet) and move towards funding programs that support the `core business' already in existence in schools. Part of the success of the current HPS project was that it appeared to help schools conduct their educational activities more effectively. From an education perspective, the chief role of the HPS framework is in achieving education goals through treating health issues within an education framework (St Leger & Nutbeam, 2000). The Health Promoting School contributes to lifelong learning skills; competencies and behaviours; specific cognate knowledge and skills; and self attributes--building blocks that are necessary for good health, health literacy and education outcomes.

It was clear from the qualitative analysis that many schools in the study began to think more holistically about health and less about teaching health topics to target community morbidity and mortality trends. What schools actually did was focus on building the foundations of health and wellbeing by using educational methods and by working towards some general educational goals (e.g. autonomy, democratic behaviours, tolerance and respect for others). There is a strong body of evidence that suggests this focus is likely to produce healthier and better educated students, as opposed to a focus on using classroom-based health education to deal with the `illth' problems of society (Devaney, Schochet, Thorton, Fasciano, & Gavin, 1993; National Health and Medical Research Council, 1996; Symons et al., 1997; World Bank, 1993; WHO, 1996).

Despite the successes of the Project, there are real challenges for the HPS movement, which are highlighted in the results contained in this paper. Clearly the language of `health' that emanates from the health sector is not central to the running of schools, or a part of teachers' thinking. On the other hand, teachers are committed to student welfare, building young people's knowledge and competencies, and safe and supportive environments for learning--all integral to HPS. Although education-focused approaches to promoting health are well accommodated by the HPS model, the issue of differing discourses between education and health remain. It is apparent that the education sector is using concepts similar to the health sector, and vice versa, but that there is a lack of acknowledgement of the links between education and health models (Cleland, 2000). Because the HPS framework was developed by the health sector in circumstances where a close collaboration with the education sector was not always practical, the framework has relied on teachers' understanding, motivation and capacity to implement it (St Leger, 2000b). The qualitative results support a future vision of health promotion in schools where projects are more embedded within educational language, systems, policies and practices. Ideally the agenda and priorities should be developed and driven primarily by the education sector, with the health sector acting as a partner and facilitator.

Reflecting the reality that the mental health agenda has converged on schools, which are currently grappling with a range of social and mental health issues (e.g. bullying, suicide, belonging, family conflict), many schools in the Project focused their HPS efforts here. Schools were concerned with promoting the emotional and social wellbeing of students, staff and families, particularly around respectful and supportive relationships, student-focused learning and participation, mediation of disputes, and staff wellbeing. However the interviews made it clear that teachers are asking for additional support and training in these areas in order to adopt effective and sustainable approaches to promoting mental health in a comprehensive way. Indeed teachers are central to the success of school health initiatives. Teachers told us that ongoing professional development is vital--teachers themselves recognise they need to build on their knowledge bases and skills in order to promote health comprehensively. The training provided in the Project was considered central to the success of the Project in the majority of schools. It is acknowledged, however, that the current levels of professional development to assist teachers to work with the HPS concept and extend learning opportunities beyond the classroom are generally inadequate.

The education sector has a challenge. There needs to be more ownership by the sector of health programs and less reliance on the health sector to fund interventions, packages and kits (Ridge et al., 2000). It became clear from this study that the educational goals of schools will be achieved more easily if they embrace a holistic approach towards health and if they own and define this work in their own terms.

Keywords

community co-operation   evaluation         qualitative research
curriculum               health promotion   school effectiveness
Table 1 The main HPS-related activities undertaken at the various
case-study schools

School   Key HPS related areas of activities

  1      * Lending outdoor equipment
         * Promoting positive relationships

  2      * Promoting healthy relationships
         * Resilience
         * Staff wellbeing
         * Healthy canteen food

  3      * Student behaviour policy

  4      * Developing a `passive' garden for
           student relaxation
         * ISDES

  5      * Staff wellbeing
         * HPS as a School Charter priority

  6      * Staff wellbeing

  7      * Staff wellbeing
         * HPS as a School Charter priority

  8      * Promoting positive school relationships
         * Staff health as a Charter priority
         * ISDES

  9      * School attendance
         * Anti-bullying
         * Towards an HPS Policy

  10     * Stress management for staff and
           students
         * Anti-bullying
         * Healthy canteen food

  11     * Staff wellbeing

  12     * Policies e.g. OH&S
         * ISDES
         * Anti-bullying

  13     * Staff wellbeing
         * Peaceable school
         * ISDES

Legend:
ISDES = Individual school drug education strategies

OH&S = Occupational health & safety
Table 2 A range of reported changes that case study school interviewees
attributed to the Health Promoting School (HPS) project

Changes for students    Changes for the school   Changes in
                                                 community links

* Increased awareness   * Increased awareness of * Networking with
  of health issues        health promotion and     local schools
* Greater student         related issues         * Establishment of
  responsibility for    * Dissemination of HPS     new links with
  actions                 ideas and learning       local agencies
* Improved student        to wider staff         * Greater knowledge,
  learning outcomes       body                     and use, of wider
* Increased physical    * Better physical          service system
  activity                environment            * Moves to formalise
* Sense of being cared  * Improved relationships   links with
  for and belonging     * Better `atmosphere' in   outside agencies
* Happier students        school                 * Greater parent
* Greater student       * Better organisation of   satisfaction in the
  involvement in          health promotion         school
  decision making         activities             * Greater involvement
                        * Better mediation of      of parents in
                          conflicts                school life
                        * Better staff morale    * Community
                        * Move toward more         involvement in
                          proactive health         school projects
                          strategies
                        * Development of school
                          health curriculum
                        * Development of health
                          related policies
                        * Incorporation of
                          health into the School
                          Charter

Acknowledgements

We would like to thank Siobhan Bowler for editing this manuscript and all informants for their valuable contributions to the study.

Notes

(1) Health literacy is defined broadly by the WHO as representing `the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health ... health literacy is critical to empowerment' (Nutbeam, 2000).

(2) Action competence is a key plank of the European Network for Health Promoting Schools. It encourages schools to have programs that enable students to take a major role in leading health-related initiatives and to build a set of competencies based on the actions they take in a democratic forum. For example, students may run the School's lunch program; set policies about appropriate behaviour; and decide on the major health issues for investigation. It is argued that following such experiences there is a shift in students' levels of empowerment (Brunn-Jensen, 1994).

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Dr Damien Ridge is the Research Fellow/Qualitative Research Consultant in the Social and Mental Health Research Priority Area, Faculty of Health and Behavioural Sciences, Deakin University, Burwood, Victoria 3125. Email: [e-mail]

Dr Jeff Northfield is a Health Promotion Consultant in the School of Health Sciences, Deakin University, Burwood, Victoria 3125. Email: [e-mail]

Dr Lawrence St Leger is a Professor of Health Promotion in the School of Health Sciences, Deakin University, Burwood, Victoria 3125. Email: [e-mail]

Bernie Marshall is a Senior Lecturer in Health Promotion in the School of Health Sciences, Deakin University, Burwood, Victoria 3125. Email: [e-mail]

Margaret Sheehan is a Lecturer in the School of Health Sciences, Deakin University, Burwood, Victoria 3125. Email: [e-mail]

Shelley Maher is a Senior Project Officer in the field of sport and recreation at VicHealth, 15-31 Pelham St, Carlton, Victoria 3053. Email: [e-mail]