Abstract
The purpose of this article is to trace development of the National Healthy School Program (NHSP) from a global concept to implementation at the local school level in England with a view toward clarifying and, more importantly, determining if implementation is proceeding as planned, as evidenced by the presence of process evaluation. The NHSP is designed to serve as a catalyst for health promotion in schools by identifying core health themes linked to evaluation principles in the whole-school approach. In this analysis, process evaluation of the NHSP whole-school approach indicates that program data are collected and recorded, but these data are not used to form an evidence-based program implementation strategy to transform the data into action. The NHSP brings valuable concepts to the global school health community that should be embraced because schools are increasingly being recognized as key settings for health promotion activities.
INTRODUCTION
The World Health Organization (WHO) defines a health-promoting school as one that responds to the dynamic needs of school stakeholders by fostering their capacity for a healthy setting to live, learn, and work. The health-promoting school:
Actively engages all members of the school community;
Provides a healthy school environment through health education and school health services parallel to community and outreach projects;
Implements policies and practices that reinforce an individual’s well-being; and
Strives to improve the health of school personnel, pupils, families, and the wider community (WHO, 2005).
Since the WHO introduced the concept of health-promoting schools in the early 1980s, healthy school programs have steadily grown across Europe and England to foster WHO healthy school principles. England (Figure 1) launched the National Healthy School Program (NHSP) in October 1999 to support the WHO concept of health-promoting schools and provide a foundation for promoting reciprocal relationships between health and education in school communities.
The purpose of this article is twofold: (a) to trace development of the NHSP from a global concept through to its implementation at the local school level, and (b) to determine if there is evidence of an NHSP process evaluation. Process evaluation reveals how a program is delivered and provides a means for stakeholders to identify if the program was implemented successfully according to plan. This analysis aims to raise awareness of the NHSP among teachers, health professionals, students, school staff, local policymakers, parents, and the community as a foundational program to foster health-promoting schools around the world. Finally, the extent to which the NHSP whole-school approach can serve as a model to the global network of health-promoting schools will be determined.
NHSP DEVELOPMENT: A GLOBAL CONCEPT TRANSFORMED TO NATIONAL POLICY
The NHSP whole-school approach was developed in October 1999 as a result of evidence to support that healthier children perform better academically and that education plays an important role in promoting health. This evidence was found in the following Department of Health policy documents: Excellence in Schools (1997), The Independent Inquiry into Inequalities in Health (1998), Saving Lives: Our Healthier Nation (1999), and Schools—Achieving Success (2001). These documents provide evidence of effective health promotion in schools and emphasize the goal for all schools in England to become health-promoting schools. The objective is to establish a national program that emphasizes the synergistic relationship of health and education outcomes.
The NHSP whole-school approach was developed in October 1999 as a result of evidence to support that healthier children perform better academically and that education plays an important role in promoting health.
With policy documents in place, the Department for Education and Employment (1999) further defined a healthy school as one that both understands the importance of investing in health to assist in the process of raising pupil attainment and improves standards by providing both a physical and social environment conducive to learning. Since development of the program, subsequent policy documents continued to support the concept of health-promoting schools: The Five-Year Strategy for Children and Learners (Department for Education and Skills, 2004a), The Healthy Living Blueprint for Schools (Department for Education and Skills, 2004b), The National Service Framework for Children, Young People and Maternity Services (Department of Health, 2004), and Every Child Matters: Next Steps (Department for Education and Skills, 2004c). Each of these documents focus on integrating health themes to maximize the health and education outcomes of children and young people in England. An enduring key feature of the NHSP whole-school approach is the support it maintains from a global concept of health-promoting schools transformed to the aforementioned national policy documents.
THE NHSP: HOW IT WORKS AT THE REGIONAL AND LOCAL SCHOOL LEVEL
The NHSP is managed jointly at the national level by the Department of Health and the Department for Education and Skills. This partnership is then supported by nine regional coordinators who assist in the development of the capacity and capability at the local school level (similar in concept to school districts in the United States). The regional coordinator is responsible for managing and profiling all stages of implementation of the NHSP whole-school approach and for administering the network of Local Healthy School Programs (LHSPs) in their respective region. Schools access support for the whole-school approach from the LHSP (Figure 2 illustrates the NHSP structure).
Each LHSP is managed by a partnership between the local education and health authorities, with a local coordinator and a team from the education and health sectors supporting its management and delivery. Participation in the NHSP whole-school approach is dependent entirely on the decision of the school principal (headteacher). There is no statutory requirement for participation in the NHSP; individual schools decide whether or not to participate. This can be taken as a mere nod of support or as a fully committed embrace of the program.
The NHSP whole-school approach is designed to serve as a catalyst for health promotion in schools by identifying core health themes linked to evaluation principles. The NHSP identifies four core health themes (personal, social, and health education; healthy eating; physical activity; and emotional health and well-being) and 10 evaluation principles (policy development; assessing, recording, and reporting pupils’ achievement; partnerships with parents and local communities; leadership, management, and managing change; staff professional development needs, health, and welfare; provision of pupils’ support services; giving pupils a voice; school culture and environment; teaching and learning; and curriculum planning and working with external agencies) (Figure 3).
Table 1 details the health theme of physical activity as an example of how the NHSP Audit Tool (Department of Health, 2005a) outlines specific criteria and the minimum evidence that schools must furnish to be working toward National Healthy School principles. The Audit Tool also provides prompts for the local education and health partnership to identify how schools can meet the outlined criteria. The Audit Tool provides a similar structure for evaluating the other three health themes.
Audit Tool criteria are derived from the 10 evaluation principles and form the basis of the minimum evidence required to demonstrate that schools are working toward the overall health theme. The Audit Tool effectively provides a picture of how the NHSP whole-school approach is implemented in the local school setting; the instrument identifies core health themes and the evaluation principles used to shape the criteria that schools must meet to support the whole-school approach. However, the Audit Tool fails to go beyond listing the criteria, minimum evidence requirements, and prompts that local schools can use to fully embrace and support NHSP principles to a whole-school approach (Table 1). An absence of descriptive guidelines regarding the interaction of health themes and evaluation principles (especially where schools are deficient in meeting Audit Tool criteria) supports the pessimistic notion that the NHSP whole-school approach represents merely an idea, not a fully developed program as intended. Consequently, the NHSP is viewed by some as a centralized plan lacking salience at the local school level.
PROCESS EVALUATION OF THE NHSP WHOLE-SCHOOL APPROACH
The second purpose of this paper is to determine if evaluation of the NHSP whole-school approach is taking place and if the evaluation is serving its intended purpose. Process evaluation is conducted to make this determination. The objective of conducting a process evaluation of the NHSP whole-school approach is to assess whether health themes are appropriately linked to evaluation principles and if mechanisms are in place to appropriately deliver the whole-school approach at the local school level. It is critical to make this determination for conceptual and practical implementation purposes of a national program. Process evaluation of the NHSP whole-school approach aims to reveal the positive and negative aspects of the program and identify ways the program can be improved so as to serve as a model program for health-promoting schools worldwide.
Process evaluation fundamentally unveils how a program is delivered and will therefore provide further detail of the NHSP whole-school approach as it supports the concept of health-promoting schools. Patton (1997) defines process evaluation as “finding out if the program has all its parts, if the parts are functional, operating as they are supposed to be operating” (p. 196). Ideally, process evaluation takes place continuously throughout the program’s implementation rather than as a post-hoc activity (Issel, 2004). Process evaluation provides a means for stakeholders, funding agencies, and program staff to identify if the program is being implemented successfully and according to plan.
Issel (2004) outlines four core purposes of a process evaluation. First, process evaluation collects data about the delivery of the program so results of impact can be interpreted within the context of the program delivery. The evaluation will identify if program standards are met and is useful to ensure that the work being done by program staff is consistent with the predefined standards. Second, a process evaluation provides operational information to new sites so programs can be replicated efficiently and successfully. Third, process evaluations meet the requirements of funding agencies, specifically in relation to demonstrating program implementation. Often, such evaluations entail collecting a predetermined set of data that can be used in a report to agencies. Fourth, a process evaluation provides continuous feedback that enables midcourse corrections in program delivery that are similar to quality improvement methods. These data are vital to the interactive nature of planning and implementing a health program that requires flexibility and especially for programs duplicated in other settings. The four process evaluation principles will be used to assess the NHSP whole-school approach.
Issel (2004) identifies data collection methods, intervention delivery, and transforming data to action as three evaluative factors used to conduct a process evaluation (Figure 4). Each factor is discussed in detail in the following section.
Data Collection Methods
There are seven categories of data that are appropriate for process evaluations. These data sets include activity logs, organizational records, client records, observations, questionnaires, interviews, and case studies. Activity logs and organizational records tend to be more specific to process evaluation. Regardless of the data collection method, high standards must be met for the quality of data collected, the reliability of the tools, and the accuracy of data entry. The choice of data collection method must be congruent with the criteria being evaluated, as well as being sufficient for arriving at a conclusion regarding the initial criteria. Consequently, there will be situations where one data set or collection method is a better choice than another (Issel, 2004). These points are taken into consideration as the NHSP data collection methods are analyzed.
The NHSP uses a combination of the seven data collection methods to gather evidence. The Department of Health (2005b) uses a combination of data collection methods for three purposes:
To minimize bureaucracy within schools,
To increase stakeholder participation, and
To maximize the degree of national consistency and rigor.
The Department of Health (2005b) values stakeholders’ views of the program over written evidence. Greater weight is given to pupils’ reporting via interviews, questionnaires, and observations in policy development than to the minutes of a school council meeting. If problems arise when there are conflicting opinions about whether the school meets a certain criterion, further work is undertaken to ascertain the validity and reliability of the evidence (trends by gender, age, classes, subjects). The school will then have to make improvements before it can be said to have satisfactorily met the criterion (2005b).
Intervention Delivery
According to Issel (2004), essential elements of a process evaluation include how well an intervention was delivered and whether the intervention was provided as designed and planned. Implementation of the NHSP is the intervention. Process evaluation is designed to detect if an intervention fails because it was a nonprogram, a nonrobust implementation, or an unstandardized implementation. The NHSP’s implementation delivery is analyzed to determine if it is failing in any of the three areas.
Nonprogram. Implementation fails due to lack of a program, resulting from a variety of factors. These factors may include a lack of physical resources, insufficient support of stakeholders, and a sophisticated delivery system that cannot be managed locally.
Nonrobust Implementation. Programs can fail if the implementation differs from or is inferior to the designed and planned regime.
Unstandardized Implementation. Implementation can fail if the implementation is provided in an unstandardized manner. By having cogent policies, procedures, and standardized materials in place, the risk for delivering a substandard implementation can be minimized.
A centralized, evidence-based program and implementation process strategy needs to be developed for the NHSP that is amenable to delivery at the local school level.
The NHSP is at risk for nonprogram, nonrobust, and unstandardized implementation. A formal, evidence-based implementation protocol for the NHSP does not exist at the national or local level. What exists is purely a framework meant to be adaptable to individual local needs. The Audit Tool (Table 1) identifies areas where local schools are lacking evidence to meet each of the criteria developed from the 10 evaluation principles that support the four core health themes (Figure 3); beyond this there are no concrete mechanisms in place to meet such deficiencies. Each school, with its own range of resources, expertise, and staff (or lack thereof), must develop a plan and process for implementing that program across some or all of the evaluation principles. A centralized, evidence-based program and implementation process strategy needs to be developed for the NHSP that is amenable to delivery at the local school level. As the program and implementation strategy are developed, officials must ensure that the program implementation has the necessary support from resources and stakeholders and is doing what it is intended to do. The program must also allow schools to adapt the implementation strategy to meet specific needs that are unique to their own community.
Transforming Data Into Action
The value of any set of data lies in how it is used (Issel, 2004). The issue is how to transform NHSP data from merely documentation of an evaluation process into information for timely feedback, evaluation, and, if necessary, corrective action. The LHSP records interview, observation, questionnaire, and Audit Tool data and houses it in a national database, for the purpose of obtaining: (1) a sense of the health of the nation’s children, and (2) an assessment as to whether the local school meets criteria as set out in the Audit Tool.
After collection is complete, the data must be analyzed and a plan must be constructed to use them to identify deficits in program implementation and to enable corrective action (Issel, 2004). Process evaluations are therefore similar to continuous quality management and total quality management methods. Systematic, reliable process data are immediately useful as quality assurance information that focuses on the level to which standards are met. Quality assurance is currently maintained by random visits to schools by officials and independent consultants. The national schools database is also used to indicate the quantitative performance of LHSPs in relation to performance of other schools (Department of Health, 2005b).
In the future, schools should include stakeholders in discussions about the accomplishments within that school as they relate to the 10 principles used to evaluate the four core health themes in the whole-school approach. Stakeholder insights can provide plausible explanations for gaps between local school performance and the criteria. Quality assurance mechanisms are in place, as are means for storing information on the nationwide network of schools, but no formal mechanism exists for transforming collected data into action to address deficiencies and improve programs. Consequently, the NHSP is a theoretical framework that is based on central policy documents and implemented at the local level, but it lacks a method of action to locally address those deficiencies it identifies. Local schools implement those features that best mesh with local resources and talents by using the criteria, evidence required, and prompts in the Audit Tool as a guide. The NHSP collects subjective and objective data about various local school activities, enters the data in a national database, and uses the data to describe what is happening in that school. The NHSP also uses the data to judge whether the school is fully embracing the whole-school approach or not participating. No plan or statutory corrective action on the national level exists, and the model does not encourage local schools to use collected data to address deficiencies.
Process Evaluation Results
The four process evaluation principles (collecting data about program delivery, providing operational information to new sites, meeting requirements of funding agencies, and providing data upon which to make midcourse corrections in program delivery) are used to determine if NHSP implementation is proceeding as planned by evidence of the presence of a process evaluation. Analysis of NHSP data collection methods, intervention delivery, and how the program transforms data to action provides an indication as to whether the four process evaluation principles are being met. Results of this analysis indicate that the program effectively collects data but fails to ensure the implementation of an intervention. Subsequently, data are transformed into action partly because there is no strategy for deficient local schools to meet criteria, which thereby bolsters both school and community resources (which support core health themes in the whole-school approach). The end result is a program that links health themes to evaluation principles through a theoretical framework but fails to demonstrate the program’s functionality in local practice due to lack of a formal evidence-based implementation strategy and a component to ensure that data are transformed into action to meet deficient needs.
Even with an implementation strategy and mechanism for transforming data into action, the success of the NHSP is more likely to be dependent on cultural changes in attitudes toward the need for a health dimension in the school setting than to the policy positions of the government. For example, nutrition and exercise in schools have been neglected for decades. In addition, issues surrounding sanitation in schools have not been addressed. England continues to have schools with outdoor toilets and still has even larger secondary schools without hot water in the rest rooms. Furthermore, playground bullying and the domination of playgrounds by boys are endemic in schools. These are health issues and are only barely coming to be noticed as such. The NHSP has the potential to play a key role in these areas, but its success is dependent on the individual school principal’s decisions about participation of each school. Conceptually, England recognizes the connection between health and achievement but has not taken the basic steps to implement programs that fund the adoption of minimally acceptable nutrition, physical activity, sanitation, and behavior standards in schools. Further development of the NHSP and a corresponding process evaluation has the potential to address and correct these deficiencies because the NHSP has an infrastructure already in place that is capable of pulling local resources to assist in simultaneously improving health and education outcomes of children.
Even with an implementation strategy and mechanism for transforming data into action, the success of the NHSP is more likely to be dependent on cultural changes in attitudes toward the need for a health dimension in the school setting than to the policy positions of the government.
The approach to service delivery from a population perspective and from a perspective that favors health improvement, well-being, and health promotion is still relatively new—and this is the perspective from which the NHSP emerged and operates. The framework and concepts from which the NHSP is derived are laudable, but it is essentially a policy position without legislative teeth. If an evidence-based implementation model program (with a well-defined means of addressing deficiencies toward meeting criteria) were developed and amenable to delivery and adaptation at the local level, the NHSP would be more likely to have an impact on health and education.
The challenge is how to translate a national framework and corresponding concept into practice at the local school level and how to do so consistently. The barriers in England at the moment are structural (staff in the health and education sectors have different paymasters and different geographic boundaries) and cultural (the very different educational and training backgrounds of health and education workers). Conceptually, the program provides a framework for supporting the global concept of health-promoting schools. However, the model has not been consistently implemented at the local school level. A means to evaluate the NHSP must also be developed because this evaluation will ultimately be a contributing factor to program success.
School nurses have an integral role within the NHSP as they bridge the health and education sectors on a broad level, fundamentally supporting the core health themes linked to evaluation principles in the whole-school approach (Wicklander, 2005). The NHSP supports school nurses in transitioning from a task-based role of screening and immunization to a public health–focused role that supports health promotion and fosters links into local strategic service planning (HDA, 2004). School nurses have a central role in supporting the NHSP at the local school level.
The NHSP provides a theoretical model for transforming the global concept of health-promoting schools into national policy that can be delivered at the regional and local levels. The program has a data collection process and an Audit Tool to assess whether local schools have met criteria specific to each of the four core health themes, and it has documented outcomes to a limited extent (Table 2). This information provides evidence of outcomes despite the lack of a prescriptive program. Process evaluation evidence, however, indicates that the NHSP solely collects and records data for two reasons. First, the NHSP falls short in addressing local school deficiencies to meet criteria outlined for each of the health themes. Second, the program fails to provide an evidence-based program implementation strategy that can adapt to individual local school needs and provide a model for local schools to transform collected data to local school, community, and resource action.
This analysis highlights the need for (a) a mechanism for local schools to address deficient areas to meet the minimum evidence required for the criteria outlined in the Audit Tool (Figure 4), and (b) a national evidence-based program implementation strategy tailored for delivery at the local level. Focus in these two areas will move the NHSP forward as a model program in the school setting to support the global concept of health-promoting schools while developing the empirical relationship between health and achievement. If the NHSP were to have a well-developed, evidence-based implementation strategy in place for delivery at local schools and a mechanism for local schools to address deficiencies to meet Audit Tool criteria, it would be better positioned to advocate for a change in cultural attitudes and to demonstrate that a health dimension is essential in the school setting.
Perhaps LHSPs that demonstrate success in meeting criteria outlined in the Audit Tool could assist in the creation of (a) an implementation strategy that would be adaptable to other local school needs and (b) a mechanism that local schools could use to address deficiencies in meeting Audit Tool criteria. Recommendations from a successful LHSP have the potential to be adapted to other local school programs. As such, it is the local coordinator who becomes responsible for sharing this knowledge amongst the range of local schools for which he or she is responsible. Figure 2 further depicts how this knowledge transfer would travel from the local level (starting with a successful LHSP) up through the regional and national levels to possibly even a global level. As local schools learn and share which strategies work (through the local coordinator, who is then responsible for transferring the information to the national level by way of the regional coordinator), they have the equally important power to foster environments that promote health within their communities and influence policy change at a regional, national, and (potentially) global level. This analysis elicits how local schools in England can translate their successes and deficiencies to provoke wider change. Action and change start locally and then spread globally.
GLOBAL VALUE OF THE NHSP
The NHSP provides its stakeholders with a recognized national framework that has identifiable health themes linked to evaluation principles that serve as a standard to bring sustained public health improvement to the complex environment of schools. This has the potential to not only bridge gaps among all levels of the educational system but to unify pupils, families, school personnel, and the public sectors. An enormous task, the NHSP is structured to create linkages and engage key players.
Wanless (2004) highlights the need to shift away from acute services and towards empowering individuals to take charge of their health behaviors through health promotion activities. The NHSP fully embraces this concept and, if further developed globally, could improve health outcomes and reduce costs for acute health services. Research efforts must focus on (a) collecting evidence that the NHSP provides a model for linking core health themes to evaluation principles in the whole-school approach; (b) developing implementation strategies that can adapt to local school needs, transforming collected data to action; and (c) identifying ways local school communities can initiate and drive the above processes. With this documentation, the NHSP will grow as a model program that translates a global concept to implementation at the local level, thereby becoming more driven and responsive to local school feedback. Despite the need to dedicate tremendous energy toward the planning, implementation, and evaluation of the NHSP, the program brings valuable concepts to the global school health community that should be embraced as schools increasingly become recognized as key settings for health promotion activities.
CONCLUSION
The purpose of this report was to trace development of the NHSP from a global concept to its implementation at the local school level and to determine if there is evidence of an NHSP process evaluation. This analysis informs schools globally of the NHSP as a theoretical model program developed at the national level and delivered at the local school level, based on the WHO’s concept of health-promoting schools. This program embeds such concepts as the four core health themes, evaluation principles in the whole-school approach, and the linkage of health and education sectors to promote health in schools; these fundamentals could serve as models that might be evaluated globally. The NHSP represents a model of an infrastructure within a global, national, regional, and local context, forging school and community partnerships for the purpose of creating healthy schools. Program implementation can be enhanced by creating a mechanism for local schools to address areas where they may be deficient in meeting Audit Tool criteria and by formulating an evidence-based program implementation strategy tailored for delivery at the local level. The importance of the local school’s role to initiate these changes by sharing knowledge, starting with the local coordinator and continuing through the regional and national levels, cannot be underestimated. This is the next step for NHSP development and will determine the extent to which the NHSP is effective in linking health and education sectors, as well as serving as a substantive and enduring feature of global health and education strategy.
Footnotes
Figures and Tables
Acknowledgments
Diane DeBell, PhD, MCMI, FRSA, Centre for Research in Health and Social Care, Anglia Ruskin University, United Kingdom; Martha Dewey Bergren, DNS, RN, BC, Department of Public Health, Mental Health, and Administrative Nursing, University of Illinois at Chicago College of Nursing; Beverly J. McElmurry, EdD, FAAN, Global Health Leadership, University of Illinois at Chicago College of Nursing.