Abstract
It has been 25 years since the Government first provided specific funding for health education in schools, but has this continued investment had much impact? Kath Sanderson, former Senior Manager in Children’s Services, Rochdale MBC, assesses health education in schools
In 1986, in response to growing concerns about drug use by young people, the Government provided the first of many years’ funding to local authorities to ensure that drug education was developed in all schools. Prior to this, most schools had provided some form of health education ranging from hygiene and dental health to lessons in wider personal, social and health education (PSHE), while a small number of national organizations provided support and resources for teachers.
There was reticence from many schools, both primary and secondary, to this initiative, since they were concerned that providing drug education would lead parents and others to think the school had a drug problem. There was general agreement that drug education should be part of wider PSHE programmes and consequently this fairly high-profile initiative became an incentive to review the wider provision, including sex and relationships education.
Health education messages are not always simple. While there is general agreement to just say no to illicit drugs and tobacco, we need to tread more carefully where parents and other family members smoke. Alcohol often comes across as ‘not now, but it is OK to drink sensibly later’, and healthy eating and exercise messages are not clear as we can eat chocolate occasionally and we do not have to exercise every day.
Not only was there much debate about what to teach, but also how to teach it. There was some success in moving away from the ‘tell them and they won’t do it’ and the ‘fear’ approaches and also from one-off talks. We also moved away from just giving children the appropriate knowledge and information in the naive belief that they would then make the healthy decisions.
Rosenstock 1 and others suggested that life skills, decision-making skills and assertiveness are key determinants of individual health action. PSHE programmes were therefore developed that included activities to nurture skills in risk taking, decision making, where to get help and coping with peer pressure, and also to promote healthy attitudes. Lessons were developed for each year group based on the premise that if all children received good quality PSHE throughout their school lives, then the likelihood would be that we would equip them to make healthier choices and to live healthier lives now and in the future. A plethora of resources were produced to support the teaching. Although there is some well-documented research on the effectiveness of specific projects, there has been little robust long-term evaluation into what influences behaviour either now or in the future.
There is undoubtedly some very good PSHE provision in schools, but on the whole it remains patchy. Through my work with schools over many years, there seem to be a number of key issues that continue to detract from its success:
The status for PSHE remains low in many schools and local authorities.
Many teachers do not want to teach it.
Both initial teacher training and in-service training for teachers is patchy, particularly in terms of purpose and methodology.
Not all children and young people receive the same PSHE and there is a lack of consistency across year groups in individual schools as well as across schools.
There remains a vagueness about what we are trying to do and the key messages we wish to deliver.
There is remarkably little robust evidence about the effectiveness of PSHE as it is currently taught.
Current Practice
During the mid-1990s, the European Health Promoting Schools model gained acceptance as one of the most powerful approaches to promoting health. 2 This was concerned with the whole school experience, not just what was taught. In the Health Promoting School, health, in its broadest sense, was intended to be at the heart of the school. Relationships, respect and consideration for others, together with the development of self-esteem and self-confidence, were seen as underpinning the day-to-day way in which pupils and staff work together.
The development of Health Promoting Schools was in its infancy when the government launched its National Healthy Schools Standard (NHSS) in 1998. This was a whole-school approach working in partnership with other agencies and parents and funded by both Health and Education Departments. Although based on the Health Promoting School model, in my view, the concept of Healthy Schools is much less rigorous than its antecedent in respect of process and outcomes.
Healthy Schools has certainly raised awareness of health issues and has provided structure and coordination. However, from my own involvement with schools I have found that the whole-school approach is often not embedded well and although much effort is applied to the process and to policy development, there seems to be less focus on high-quality teaching and learning of PSHE. Many schools collapse PSHE into Health Weeks, again with no evidence of impact. Independent research in 2009 3 revealed significant links between achieving and working towards the NHSS, and better Ofsted ratings of school-effectiveness. While this is very positive, there is still little evaluation of the impact of Healthy Schools on long-term health-related behaviour changes.
The government funding has provided additional support to schools, and 97% of schools are currently involved with the Healthy Schools programme at some level; 4 it has been hailed as a success by ministers. The current Healthy Schools toolkit provides a ‘plan–do–review’ approach and suggests that schools develop action plans and choose evidence-based activities to meet the desired outcomes. Given that there is little evaluation to work with, this is probably a difficult task for schools.
The current Department for Education (DfE) website highlights the NHSS aims: 4
To improve standards in health and education and to tackle health inequalities and to make children, teachers, parents and communities more aware of the opportunities that exist in schools for improving health.
While these are laudable aims, they are somewhat removed from ensuring long-term healthy behaviour.
Conclusion
Twenty-five years on from the first specific health funding for schools, pupils do receive more health education and the likelihood is that there will have been real benefits. Nevertheless, provision is not equitable between schools, either in terms of quality or quantity. There is still no clear evidence of effectiveness or of any significant impact on short- or long-term behaviour. Schools are only one influence on children and young people, but they are the only agency in very regular contact with all of them. As such, schools can have a huge impact on their students’ health and we need to pursue this opportunity to the very best of our ability.
At present, we seem to be at an impasse, continuing to do what we have always done. In order to move forward we need the following:
A clear understanding and agreement about the intentions of health promotion for children and young people.
Clarity about the desired outcomes and the evidence we need to demonstrate success.
An understanding and agreement about the role schools should play and the impact they can have.
A review of how best this can be delivered in schools, in particular which interventions will deliver the desired outcomes.
Clarity about what is required of schools and individual teachers to achieve this.
Consensus about the role of other agencies.
Clear commitment, at all levels, that children deserve better than they have had so far.