Health Promotion In Schools Research Paper

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Health promotion in schools is a topic of both practical and empirical interest. Schools which provide comprehensive school health promotion programs are more effective in encouraging children to adopt health enhancing behaviors and in reducing health-compromising behaviors than schools that provide health education alone. Research into the effectiveness of comprehensive school health programs provides evidence of the positive influence that such programs can exert on student health behaviors. However, conditions that enable effective school health promotion programs to be initiated and maintained depend on several school organizational and program implementation factors.

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1. Changing Concepts Of Health Promotion

The meaning of health and health promotion have been transformed over the 1990s. Influenced by the World Health Organization (WHO), health is seen as more than avoiding illness. Similarly, health promotion involves more than helping people to choose healthy lifestyles.

Health promotion in the USA, Canada, and Western Europe has been influenced by WHO concepts contained in the Ottawa Charta for Health Promotion (1986). Health is viewed as a resource of daily living, a positive concept emphasizing social and personal resources, as well as physical capacities. Responsibility for health rests not only with the health sector, but includes building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. Accordingly, health promotion professionals are expected to work for health through advocacy, enabling individuals, and mediating among diverse sectors. Developments since the Ottawa Charta suggest increasing awareness of the role values play in health-related activity as well as increasing emphasis on social justice, reducing inequalities, and enhancing social cohesion. The Jakarta Declaration on Health Promotion in the 21st Century (1997) finally outlined priorities for promoting social responsibility for health, increasing investments for health development, increasing community capacity, empowering the individual, and securing an infrastructure for health promotion.

Currently, the ever-widening gap between rich and poor is an issue of great concern, and compelling evidence confirms that exclusion, both societal and material, is highly linked to health problems. The potential effects of inequalities on the health of populations have first been stressed by The United Kingdom Charta for Health Promotion, followed by reports from Canada and the US which reported profound variation in health and well-being between poor and nonpoor children. Health inequalities exist in level of mortality and morbidity, accidents and injuries, risk behavior, mental health, school achievement, and family violence. These differences have traditionally been interpreted in terms of risk behaviors resulting from lack of education, and material deprivation. Yet, careful analyses indicate that most of the variance in health outcomes among differing social classes is not accounted for by lifestyle factors. Recent analyses challenge the ‘risk group’ metaphor, showing that American and European children and adolescents in high-risk settings (low income families, high unemployment of the caregivers, poor neighborhoods) were in poorer health than those living in wealthier settings.

2. Health-Promoting Programs

Numerous health-promoting programs have been published; the focus diverges with some publications emphasizing public health concerns and other reflecting an education perspective. In addition, the programs vary with respect to age range, comprehensiveness, theoretical background, and the importance of evaluation. While some studies comprised primarily of survey data, others examine the effect of intervention programs. Several papers incorporate a substantial body of epidemiological and demographic data as basis for their conclusions. Most discuss policy options and recommendations. Thus, substantial variation exists with respect to such factors as level of detail, use of research data, intended audience, and political viewpoint.

Rather than giving an overview of the current state of research in school-based health promotion (see David and Williams 1987), in the following, some examples of comprehensive programs will be given, prominent trends will be presented, and, finally, frequent domains in health promotion programs will be evaluated.

To date, not many prevention and intervention programs have incorporated the important developments in health promotion values and principles. The Dartmore Health Promotion Study (McIntyre et al. 1996) is one of the rare programs that coordinated school health instruction, health services, and a healthful environment to enhance the program’s effect on the health of the heart and mental health of children in grades four, five, and six. Several studies suggest that children are not engaging in physical activity of sufficient length and intensity to improve cardiovascular fitness; during adolescence, the amount of physical activity further decreases. This has resulted in the development of community-wide Youth Exercise Promotion in order to prevent heart diseases and to influence blood pressure in pupils with risk for hypertension.

To give an example, the CATCH (Child and Adolescent Trial for Cardiovascular Health) is the most comprehensive multilevel program which has been extensively evaluated (Perry et al. 1997). The interventions targeted changes at the school level (food services offerings and minutes of class time devoted to physical activity) and at the student level (psychosocial factors, dietary behaviors, physical activity levels, smoking intentions, physiological indicators). The CATCH interventions consisted of: (a) Eat Smart, a school food service program to provide children with meals reduced in fat and sodium; (b) Catch PE, to increase the amount of time students spent in physical activity at school and for other times of the day; (c) Hearty Heart and Friends, 15 classroom lessons to teach dietary and physical activity information through a series of stories; and (d) Family Fun Nights, during which pupils and family members participated in 90 minutes of games, fitness-related activities, and healthy snacks.

Generally, health promotion programs have been confined to highly selective programs designed to identify specific health risks, such as tobacco smoking, alcohol consumption or drug use, and to train health promoting behaviors, for example with respect to prevention of HIV. Most of these programs are designed for late childhood and early adolescence and pursue multiple strategies for preventing health damage, including more traditional strategies (for example, teaching drug information and/or general communication and problem-solving skills) and approaches based on the social influence model (which emphasizes strategies for identifying and resisting social pressure to use drugs or alcohol). Time reserved for cognitive instruction was usually low, with most curricula ranging between 5 and 15 lessons. Although the overall cognitive progress in most programs was impressive, this was not sufficient to produce corresponding reduction in use of alcohol, drug or nicotine. Mostly, the effects were stronger and longer lasting for girls than for boys. Frequently, developmentally relevant variables are incorporated, for example increasing peer pressure or a risky lifestyle during adolescence. Resistance-Skill Training(s), however, was not always found to be effective strategies for preventing the onset of alcohol, drug or tobacco use; sometimes counterproductive effects were found.

Health promotion in middle schools is a neglected area, although the middle school years are a time of increasing risk for negative health related outcomes. Health promotion in the middle school mostly focuses on two approaches, a social decision approach (e.g., teaching strategies and skills that help children to make favorable decisions when confronted with health damaging situations and offers) and social skills training (in which children are prompted, coached, and guided to practice using the skills). These approaches are based on the observation that children are unlikely to retain and use information conveyed solely through formal lessons; they need opportunities for reinforcement and practice. Further, not many health promotion or health education programs are developed for elementary school children. The Claxton Elementary School Health Program (Landis and Janes 1995) is one of the rare examples. In this project, school administrators, parents, and local physicians worked together to discover what types of healthy and unhealthy activities children and parents are engaged in, and identified which health problems are of greatest concern to parents and teachers.

Professionals in school health education have frequently emphasized parent and family involvement in school health education. Unfortunately, preparing prospective educators for such involvement often has been overlooked. Teacher training for involving families in school health education were designed to provide staff members with the background necessary to incorporate family involvement concepts and activities into their classes. This may include, for example, (a) newsletters to provide information about health and the school health program to family members, (b) family calendars about quick activities—less than five minutes—that families can do daily, and (c) information about children’s books, television programs and movies that address health topics.

Recently, the interaction with families of high-risk children became a major focus, particularly in settings outside school. The Triple P Program, for example, aims at helping parents of kindergarten children with sleeping and eating disorders to cope with these challenges by developing positive parenting attitudes and behaviors. Although it targets categorical symptoms rather than their common antecedents, it is highly valuable for preventing more severe future health problems in offspring.

To summarize, health promotion and education programs focus on late childhood and adolescent subjects and target problem behavior (which is highly inter-related such as drug and alcohol use) and unhealthy life styles (with respect to nutrition and physical activity). Stress prevention programs or programs teaching functional coping skills are less frequently applied. Most programs are centered in and around schools, but preventive approaches sometimes reach out to families with preschool children at risk

3. Evaluation Of School-Based Prevention And Intervention Programs

Quantitative research summaries are needed to deal with questions such as the relative efficacy of prevention and intervention programs with different aims and program orientations. In assessing program outcomes, five criteria should be met: (a) the use of appropriate comparison groups; (b) the use of appropriate pretests, post-tests, and follow up assessments; (c) examining research attrition; (d) the validity of dependent variable assessments; and (e) the use of statistical procedures appropriate for program evaluation research. In the following, quantitative reviews of prevention and intervention programs targeting adolescent drug use, smoking, and alcohol consumption were presented. They represent a new approach in that program classification schemes were used to categorize outcome, which were then employed in a quantitative meta-analysis of study effect size, based on the above criteria.

3.1 Meta-Analyses Of Smoking Prevention Programs

A substantial number of research report evaluating programs designed to prevent adolescent smoking have been published in the 1980s and 1990s. A very important set of questions deals with: (a) how successful these programs have been in general; (b) whether programs of different orientation show different levels of success; and (c) what variables, in addition to program orientation, may account for different levels of success. The meta-analyses conducted by Bruvold (1993) was based on 94 separate intervention studies published between 1970 and 1990. These studies evaluated school-based programs designed to deter adolescents from smoking tobacco products and were screened for methodological rigor. Each study reviewed was independently evaluated on the five methodological criteria detailed above. Fortyeight studies with adequate and defensible method-ology were included in the meta-analyses. Program classification revealed four different types of orientation of the prevention program: (a) rationally oriented information approach; (b) developmentally oriented affective education; (c) social norms-oriented alternatives; and (d) social reinforcement-oriented social pressures approach. The rational model supports traditional classroom interventions where information about the short and long-term health effects of tobacco is didactically presented. Reinforcement, social norms, and developmental interventions have two features in common: all are relatively new, and all were developed because of dissatisfaction with the uncertain effectiveness of the traditional didactic approach. Weighted average effect sizes were computed for all 48 better methodology studies for knowledge, attitude, and behavior, respectively. Positive results with similar high effect sizes for knowledge were found in programs with developmental, social norms, and social orientation. Results for attitude were generally not as positive. Programs classified primarily as social reinforcement-oriented seem to have had the most impact on attitudes, followed by those classified primarily as developmental. This suggests that newer orientations were more successful in modifying attitudes than more traditional rational approaches. Behavioral effect sizes were found to be largest for interventions with a social reinforcement orientation, moderate for interventions with either a developmental or a social norm orientation, and small for interventions with the traditional rational orientation. Altogether, the results of this meta-analyses suggest that rational orientation had very little if any impact on behavior and attitudes, and that the developmental and social reinforcement orientation revealed similarly positive effects on attitudes and behavior. Not much difference, depending on program orientation, emerged with respect to the cognitive outcome.

3.2 Comparison Of Tobacco And Alcohol Intervention Programs

Frequently, school-based interventions were designed to deter children and adolescents from starting to consume alcohol and tobacco, and to convince those already consuming these substances to stop or reduce consumption. Bruvold and Rundall (1988) conducted a meta-analysis on those programs that combined tobacco and alcohol prevention. Again, they classified the programs according to their theoretical orientation into rational, social reinforcement, developmental, and social norms. In addition, the major methodological requisites for research evaluating school-based tobacco and alcohol interventions detailed above were applied to the studies incorporated in the metaanalysis. Altogether, 19 studies were found which had a control or comparison group, reported attrition rate, employed pretest, post-test and follow-up measures, and used adequate statistical analyses. A very consistent result was that the intervention program, based upon the rational model produced fewer positive behavior and attitude effects but more positive knowledge effects than those in which the rational model was not dominant. Knowledge effects were consistently positive over all studies reviewed, but attitude effects were mixed, some positive and some negative. For smoking behavior, the effect size was satisfactory for long- and short-term measures, but behavioral results for alcohol were meager for long- and short-term measures. Thus, while the alcohol interventions had an effect in the desired direction on alcohol consumption, the average impact was not as large as that for smoking.

3.3 Effectiveness Of Drug Abuse Resistance Education

School-based drug prevention programs have been an integral part of the US and European antidrug campaign during the 1980s and 1990s. Although programs have proliferated, Project DARE (Drug Abuse Resistance Education) is the most widely implemented school–based, drug use prevention program in the United States, and has been adopted by approximately 50 percent of school districts nationwide. The drug prevention curriculum offers 17 lessons, usually once a week, and is applied in elementary schools, as well as in junior and senior high schools. Lessons focus on teaching pupils the skills needed to recognize and resist social pressures to use drugs. In addition, lessons focus on providing information about drugs, teaching decision-making skills, building self-esteem, and choosing healthy alternatives to drug use. Didactics include lectures, group discussion, question and answer sessions, audiovisual material, workbook exercises, and role playing. Ennett et al. (1994) used meta-analysis to review methodological rigorous evaluations of short-term effects. The DARE effect size for drug use behavior was very low across the studies. For all outcomes considered, the DARE effect size means were substantially smaller than those of programs emphasizing social and general competencies and using interactive techniques. Considering the enormous amount of public funding for DARE, the short-term effectiveness of DARE for reducing or preventing drug use behavior can not be considered as satisfactory.

4. Implications For School Health Programs And Personnel

The School Health Education Evaluation indicated that for school health education to promote health for children, schools should devote at least 50 hours of classroom time each year to health instruction. However, in many industrialized countries, particularly in southern and eastern Europe, these standards are not met (Takashini and Hamburg 1997). Limited resources, including curricular time, make it unlikely that health promotion in schools will realistically increase in strength. Thus, it is important to develop more efficient ways to promote children’s health, for example by adding complementary interventions to school health education from other sources.

Meta-analyses of more recent school-based studies show that it is necessary to carefully evaluate the programs. Overall, improvements of methodology and conceptualization of programs is noticeable, but still a need exists to upgrade substandard procedures regarding experimental attrition and establishing the validity of dependent variable measures. Further, there is a need for developing program intervention models that clearly and fully follow tenets of the guiding theory. In addition, prevention and intervention programs which have been designed and evaluated so far are largely confined to certain age groups (frequently to adolescents) and limited to the treatment of problem behaviors (such as drug, alcohol, or tobacco use). The health needs of younger ages, for example preschool children or children from grades one to five, are largely neglected.

Based on the recent developments of health promotion values and principles detailed in the Jakarta Declaration, health promotion in schools should acknowledge societal factors such as inequalities and poverty as important determinants of health in children and adolescents. Health promotion in schools therefore has to incorporate the community level of life quality in designing programs. School health personnel need to deal with issues that influence children and youth’s health, but is beyond the traditional focus of health education and behavior change. They need to assess the quality of life as it is perceived by children and adolescents, and identify the specific needs of individual children. Then, community-based action can be developed to address these issues.


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  5. Jakarta Declaration on Health Promotion into the 21st Century 1997 World Health Organization, Geneva
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