Escolar Documentos
Profissional Documentos
Cultura Documentos
Pauline Dickinson
Glenalmond Research, IT & Counselling Ltd
2005
Contents
1. Executive Summary .............................................................................................................................. 4
Literature Review Findings........................................................................................................................ 4
2. Introduction ........................................................................................................................................... 8
2.1. Background....................................................................................................................................... 8
2.2. Methods .......................................................................................................................................... 10
2.3. Structure of this literature review .................................................................................................. 11
2.4. Acknowledgements ........................................................................................................................ 12
2.5. Terms, Definitions and Abbreviations........................................................................................... 12
3. Overview of international initiatives to promote wellbeing in school settings............................ 14
3.1. The World Health Organisation’s Global School Health Initiative ............................................. 14
3.2. UNICEF’s Child Friendly Framework .......................................................................................... 15
3.3. FRESH-Working together to Focus Resources for Effective School Health............................... 16
3.4. INTERCAMHS: the International Alliance for Child and Adolescent Mental Health and
Schools 16
4. International models of practice for the promotion of wellbeing in school settings .................. 19
4.1. A whole school approach ............................................................................................................... 19
4.2. International Models of Practice for Promoting Wellbeing in Schools ....................................... 22
5. The links between mental, emotional and social heath, nutrition, physical activity and
learning and achievement........................................................................................................................... 40
5.1. The promotion of mental, emotional and social wellbeing in school settings ............................. 40
5.2. Physical activity, nutrition and mental health ............................................................................... 50
6. Criteria for the effectiveness of Health Promoting Schools evaluation ....................................... 54
6.1. Issues for evidence-based practice for HPS .................................................................................. 54
7. International audit tools for schools ................................................................................................. 57
7.1. The psycho-social environment profile (PSE) (World Health Organisation, 2003).................... 57
7.2. MindMatters Audit Tools............................................................................................................... 58
8. Concluding comments ........................................................................................................................ 59
References..................................................................................................................................................... 62
Appendix: Audit Tools................................................................................................................................ 67
Table One: Self-esteem example of the ways in which EHWB can be fostered in the school
setting ....................................................................................................................................24
Table Two: Leadership and management/school culture and environment/policy development
...............................................................................................................................................25
Findings from international literature have indicated that globally, HPS initiatives
share a socio-ecological model of wellbeing, which is characterised by building strong
partnerships and collaboration between schools, families and communities, children
and young people and key policy makers in the education and health sectors. Of
significance is the emphasis of these initiatives on quality teaching and learning
conditions based on respect, inclusiveness, safety, creativity and relevant curriculum
which can motivate learning and achievement for children and young people. Each of
these initiatives has, in recent years, begun to focus on the quality of the psychosocial
environment and the way in which this impacts on the mental, emotional, social and
physical wellbeing and learning and achievement processes and outcomes for children
and young people.
(a) Learning and achievement: links with mental health and emotional
competence
The literature reviewed indicated that school-based initiatives that focus on promoting
mental health and emotional competence have a direct effect on educational
achievement. These initiatives also affect factors such as achieving a more positive
school ethos, positive self-esteem, listening and communication skills among young
people. For schools to be effective in both learning and achievement, four key
elements were identified as essential for schools to develop among staff and students:
supportive relationships; a high level of participation; encouragement of autonomy;
and clear rules, boundaries and expectations.
(d) Learning and achievement: links with nutrition and physical activity
The literature reviewed indicated that there were strong associations between physical
activity, nutrition and learning and achievement. Of particular relevance were global
findings, which indicated that levels of regular physical activity had reduced for
children and young people over the past thirty years. Childhood obesity has also
increased nationally and elsewhere. Findings indicated that children and young people
who were overweight were more likely to experience poor mental health due to the
impact of teasing and bullying, which resulted in their feeling isolated and lonely as
well as impacting negatively on their learning and achievement. The literature
reviewed signalled that caution was needed in the design of health promotion
strategies to address child and adolescent obesity due to possible further
stigmatisation concerns.
2.1. Background
HPS in Aotearoa/New Zealand
In Aotearoa/New Zealand HPS was introduced to the education sector at a school
level and has been driven by health sector policy and personnel with the broad goals
being to improve the wellbeing of children and young people in schools. The way in
which HPS was introduced as a significant pilot initiative in the Auckland and
Northland regions, was gradually adopted throughout the country. However, there are
now diverse implementation models operating in different regions.
Health Promoting Schools Practitioners around the country have been expanding their
work with schools and their communities with the HPS model and success stories
being promoted through many avenues. This activity has resulted in increasing
interest and demand from schools throughout the country, beyond the capacity of HPS
Practitioners. HPS Practitioners have asked for a “do it yourself” toolkit for schools
and have, in recent feedback, reflected the need for reorientation of HPS Practitioners
towards more of an advisory role with HPS being driven from within schools. To
champion HPS as a lead model, practitioners have expressed their need for nationally
consistent training, tools, language, planning, implementation, and assessment
approaches that strengthen capacity and build a robust national workforce.
A stocktake of HPS resources has recently been completed as stage one of of a two-
stage project towards developing a nationally consistent toolkit for use by HPS
practitioners and schools in the implementation of HPS. This stocktake identified that
More recently, the Ministry of Health, Ministry of Education and SPARC have signed
a tripartite agreement which has initially prioritised nutrition and physcial activity as
the key areas of action for HPS in Aotearoa/New Zealand. Mental health has also
been prioritised by the Ministry of Health through various regional contracts. Given
the inextricable links between nutrition, physical activity and mental, emotional and
social wellbeing, the literature and initiatives reviewed for this report highlight
research findings in these three key areas.
2.2. Methods
Literature review
The focus of this review is on international and national literature and models of
practice for HPS. The materials reviewed fall into the following categories:
• Reviews of research
• Reports of initiatives
• Research reports
• International and national survey reports
• Discussion documents and articles
As well as research published in peer reviewed journals, ‘grey’ literature has been
included that represents work that is well-respected by various government
departments. Case studies are one example from this ‘grey’ literature that represents a
considerable body of work that has been done in the HPS field. A search of the World
Wide Web also identified a range of school-based health promotion initiatives. The
data bases searched for peer-reviewed research were:
The following key words were used alone or were combined: schools / health
promoting schools / mentally healthy schools / psychosocial environment /
psychosocial/ young people / children / school-based / schools / teaching / learning /
achievement / nutrition / bullying / student wellbeing / adolescent health / child health
/ emotional competence / emotional wellbeing / whole school approach /. Key word
searches were also combined with countries known to be developing and
implementing Health Promoting/Healthy School initiatives such as Australia, New
Zealand, Canada, United Kingdom, and United States.
The literature reviewed within the timeframe for this project provides an overview of
key areas of HPS policy and practice internationally. While current HPS/school health
literature acknowledges a holistic approach to wellbeing, considerable attention has
been given to the promotion of mental, social and emotional wellbeing, particularly at
a global level and through the European Network of Heath Promoting Schools. It is
also important to acknowledge that while there are many regional networks
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 11
throughout developed and developing countries, it is likely that there may be other
HPS initiatives, particularly within indigenous groups, that have not yet been
documented.
2.4. Acknowledgements
Thank you to the Health Promoting Schools practitioners throughout Aotearoa/New
Zealand who have shared their resources.
Mental health
A school’s environment can enhance social and emotional wellbeing, and learning
when it: is warm, friendly and rewards learning; promotes cooperation rather than
competition; facilitates supportive, open communications; views the provision of
creative opportunities as important; prevents physical punishment, bullying,
harassment and violence, by encouraging the development of procedures and policies
that do not support physical punishment and that promote non-violent interaction on
the playground, in class and among staff and students; and promotes the rights of
children and young people through equal opportunities and procedures (World Health
Organisation, 2003).
Clarification of reporting
It is readily acknowledged that health and education outcomes for young people are
inextricably linked, and that the school, as a setting, has the capacity to both promote
and support health and wellbeing as well as learning and achievement (Battistich,
Schaps, & Wilson, 2004; Resnick et al., 1997; Resnick, Harris, & Blum, 1993;
Samdal, Nutbeam, Wold, & Kannas, 1998).
Over the past decade international initiatives that have focused on promoting and
supporting the wellbeing and education of young people, in the contexts of school,
family and community, have been championed by the World Health Organisation
(WHO), UNICEF, Education for All (EFA) and a recent interagency initiative by
WHO, UNICEF, UNESCO, Educational International, Education Development
Centre, Partnership for Child Development and the World Bank, titled Focusing
Resources for Effective School Health (FRESH) (World Health Organisation, 2003).
• the school is a significant personal and social environment in the lives of its
students;
• the school environment is physically safe, emotionally secure and
psychologically enabling;
• teachers are the single most important factor in creating an effective and
inclusive classroom learning and teaching environment;
• the school recognises, encourages and supports students’ growing capacities as
learners by providing a school culture, teaching behaviours and curriculum
content that are focused on learning and the learner;
• the ability of a school to be and to call itself child-friendly is directly linked to
the support, participation and collaboration it receives from families;
• the school develops a learning environment in which girls and boys are
motivated and able to learn, and staff members are friendly and welcoming to
children and attend to their health and safety needs.
Education for All (EFA) is an initiative with a vision to enable children, young people
and adults to experience educational opportunities that will enable them learn, achieve
and have their basic needs met. The Dakar Framework for Action, Education for All:
Meeting our Collective Commitments includes the creation of safe, healthy, inclusive
and equitably resourced educational environments that enable children and young
people to learn effectively. The EFA framework calls for policies and codes of
conduct that enhance the physical, social and mental and emotional wellbeing of
teachers and learners (UNICEF).
• health-related policies that help ensure a safe and secure physical environment
and a positive psychosocial environment, and address all types of school
violence, such as the abuse of students, sexual harassment and bullying;
• safe water and sanitation facilities;
• skills-based health education that focuses on the development of knowledge,
attitudes, values and life skills needed to make and act on, the most
appropriate and positive decisions concerning health; and
• school-based health and nutrition services which are simple, safe and familiar,
and address concerns that are prevalent and recognised as important in the
community (UNICEF).
INTERCAMHS currently has over 250 members who represent 26 countries. The
Alliance aims to promote the exchange of ideas and experience through strong links
with people with expertise in child and adolescent mental health with the aim being to
enhance the wellbeing of children and young people. An advisory board was formed
which includes members from Australia, Germany, United Kingdom, United States,
Ireland, New Zealand, Vietnam, Canada, Azerbaijan and Iceland.
The Alliance was established in 1998 and in October 2003, INTERCAMHS inaugural
meeting was held in conjunction with the 8th Annual Conference on Advancing
School Mental Health in Portland, Oregon. The theme for the meeting was
represent the full continuum of mental health promotion, early interventions and
treatment in schools. Such an approach will also help overcome the stigma that so
damagingly continues to surround the whole issue of mental health (p.66).
The Alliance, in focusing on global mental health, aims to connect the promising
work in school based mental health through the development of collaborative
approaches across states, regions and countries. As Weare (2004) has stated:
there is a particular need for strategies to ‘bridge the cultural divide’ between
education and mental health, as schools often find it hard to see the relevance of
mental health to their central concern with learning. A critical issue will be to
understand the nature of schools, their role in society, their culture, and how these
factors promote or mitigate against school mental health promotion efforts. The
meeting uncovered some significant cross-systems (e.g., education and health)
initiatives for whole school mental health promotion efforts such has MindMatters,
originally an Australian project which has been adapted and adopted in Germany and
is being considered elsewhere in Europe. (p.66).
In summary the global school-based health promotion initiatives reviewed share the
following characteristics:
This section describes a ‘whole school approach’ to promoting wellbeing and includes
examples of international models of practice for Health Promoting Schools/Healthy
Schools from the United Kingdom, Scotland, United States of America, Canada,
Europe and Australia.
Within an ecological framework, there is scope for both the enhancement and
promotion of protective factors, both at an individual and an environmental level.
Kalafat (2003) has suggested that even when there are risk conditions present among
groups, whole school approaches to promoting wellbeing can assist in mediating
against risk. With regard to mental health, Beautrais (1998) has identified a wide
range of components of positive mental health promotion programmes such as:
increasing the awareness of mental health concerns; destigmatising mental illness;
encouraging students to recognise signs of poor mental health among themselves and
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 19
their peers; ensuring that young people are able to access appropriate support/help
seeking for themselves and their friends; and life skills development/enhancement in
the areas of self-awareness, coping, social and problem-solving skills.
In keeping with this ecological perspective, Phelan and colleagues (1994) have
proposed a concept of multiple worlds as a framework for conceptualising the various
transitions that occur for children and young people. These multiple worlds (Figure 1)
comprise the family, peer group, school and wider community in which children and
young people engage and interact, with these worlds being interrelated. The meanings
and understandings that they derive from their multiple worlds combine to influence
the way in which they navigate the mental, emotional and social challenges that they
face and the way in which they engage with schools and learning. The concept of
transition and change in this model is considered in its broadest sense and offers a
framework for schools to support children and young people to successfully navigate
their worlds. One of the most useful features of the multiple worlds’ model is that it
directs attention to the nature of boundaries and borders as well as processes of
movement between the worlds. In this way children and young people are construed
as mediators and integrators of meaning and experience, as they adapt to the different
contexts and settings in which they grow and develop.
Figure 1: The multiple words model
FAMILY SCHOOL
• Home • norms
• values • values
• beliefs • beliefs
• expectations SELF • expectations
• actions • meanings • actions
• perceptions
• understandings
• thoughts
• feelings
• adaptation
LARGER strategies LARGER
SOCIO- SOCIO-
PEERS
ECONOMIC • norms ECONOMIC
• values
COMMUNITY • beliefs COMMUNITY
•
expectations
• actions
Community Links
And Partnerships
With the core business of schools being education, effective health promotion requires
that the emphasis shifts from an exclusive focus on classroom specific education or
programmes, towards a more comprehensive outlook in which health promotion
operates consistently across the curriculum, the school environment, and school
partnerships and services, and is integrated with appropriate structures, policies and
programmes with in the school (Bennett & Coggan, 1999; Patton et al., 2000; Wyn et
al., 2000). Hence, education outcomes and health promotion become inextricably
linked in enhancing the healthy development of children and young people. In
adopting a whole school approach to wellbeing schools can serve as a protective
shield to help children and young people navigate their various life challenges and
daily experiences within the context of a supportive social, emotional and physical
environment.
In the United Kingdom the National Healthy School Standard (NHSS) sponsored by
the Department for Education and Skills (DfES) and the Department of Health and
managed by the Health Development Agency (HDA) aims to contribute to raising the
achievement of children and young people, promote social inclusiveness and reduce
health inequalities (World Health Organisation, 2003). One theme of the NHSS
focuses on the emotional health and wellbeing (EHWB) of children and young people.
To meet the NHSS criteria for EHWB schools are required to demonstrate that they:
• provide opportunities for student participation and obtain their views to inform
policy and practice;
The National Healthy Schools Standard (Emotional health and wellbeing – including
bullying) – United Kingdom
It is worth remembering that there are no quick fixes for achieving the full benefits of
a concerted EHWB programme. It takes time to develop whole school practice that
truly promotes EHWB, and programmes need to be implemented rigorously,
continuously and in an emotionally literate way to get results (NHS Health
Development Agency, 2004).
The National Healthy Schools Standard (NHS) document has been developed by the
NHS to provide support for staff and practitioners working in or with schools to
promote emotional health and wellbeing (EHWB). It is noted in the document that the
primary school sector has more readily embraced the promotion of emotional health
and wellbeing than the secondary school sector. The National Healthy Schools
Standards whole school approach to promoting emotional health and wellbeing
focuses on ten elements:
• Policy development
• Curriculum planning and resourcing
• Teaching and learning
• School culture and environment
• Giving students a voice
• Provision of students’ support services
• Staff professional development needs, health and welfare
• Partnerships with parents, carers and the community
• Assessing and recording and reporting achievement
• Leadership, management and maintaining change
Each aspect builds on and supports each other and the activities that support them
often overlap. The initiatives/activities have been referred to as ‘taught’ elements
(e.g., curriculum based) and ‘caught’ elements (e.g., a positive whole school
approach). The National Healthy Schools Standard emphasises action planning and
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 23
the development of both short-term and long-term targets with the central premise
being that “a piecemeal adoption of strategies, important as each of them might be, is
less effective in terms of the impact on pupils and staff than a whole school approach,
and less sustainable over the longer term” (NHS Health Development Agency, 2004).
This document also provides information and practical strategies for schools to
become more emotionally healthy by enabling them to meet the specific criteria for
the NHSS theme of EHWB and to reinforce and extend good practice in this area,
beyond that described in the NHSS criteria. Section one discusses the language of
emotional wellbeing, social, emotional and behavioural skills necessary for EHWB,
reasons why schools should promote EHWB and provides a case study of an
emotionally healthy school. Section two describes the links between emotional health
and learning and the ways in which children and young people can achieve their
potential. Five areas of need are presented: (1) physiological or survival needs; (2)
safety needs; (3) love, affection and belonging; (4) self-esteem; and (5) self-
actualisation. For each area of need, the document describes the desirable experiences
for individuals and what this might look like in the school setting.
Table One: Self-esteem example of the ways in which EHWB can be fostered in the school setting
Self-esteem • Being valued, accepted • ‘Star of the day’ events to be the focus of
and celebrated positive attention
• Being noticed and • Use of praise
listened to • Use of appropriate language to correct
• Influencing outcomes behaviour
• Being supported to take • Rewards and recognition systems
responsibility for • Opportunities to have special
outcomes with responsibilities
increasing
independence
(NHS Health Development Agency, 2004)
Section three presents an overview and practical examples of the ten elements of the
NHSS whole school approach. For example, the element ‘Leadership, management
and managing change’ is considered critical in providing support and direction for
promoting EHWB in the school community. As with other HPS initiatives, “leaders
set the tone for all interactions within the school environment, so their use and
modelling of SEBS is critical” (p.26) The EHWB resource also provides an overview
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 24
of the policy context for the ‘emotionally healthy school’ (p.26), national education
strategies, other policies and strategies such as local preventive strategies, child and
adolescent mental health services; and a comprehensive analysis of a range of
resources that schools could find helpful in supporting their work under the different
strands of the EHWB theme. One example of the analysis framework as related to
inclusiveness is shown in Table Two.
In summary, the NHSS Promoting emotional health and wellbeing briefing document
provides a sound rationale, practical strategies and case study examples to enable
schools to achieve this standard. Two useful features of this document are: the ways
in which each of the ten NHSS standards function with regard to the promotion of
emotional health and wellbeing; and the comprehensive analysis of available
additional community and national resources available to schools.
The Leicestershire HPS initiative identifies eight key themes and includes an audit
tool for each one. The eight themes are:
• Personal, social and health education (PSHE)
• Citizenship
• Drug education
• Emotional health and wellbeing
• Healthy eating
• Physical activity
• Safety
• Sex and relationships
To gain recognition as a Leicestershire HPS school the school will need to show that
they have:
• a commitment to a whole school approach in implementing appropriate policy
development in the area of health promotion;
• a named person to coordinate developments;
• an action plan for school development;
• a task group to lead activities; and
• involvement at some level of students, parents/caregivers, staff, senior
management, governors, school nurse, and outside agencies as appropriate.
(http://www.leics.gov.uk/print/health_school_process)
‘Health’ is taken to mean physical, social, spiritual, mental and emotional wellbeing
in relation to oneself, society and the environment (Scottish Health Promoting
Schools Unit, 2004, p.iii).
In Scotland, the Being Well – Achieving Well initiative has been established with the
goal being that by 2007 all schools will become HPS (Scottish Health Promoting
Schools Unit, 2004). This project has been established by the Scottish Health
Promoting Schools Unit (SHPSU) in partnership with national and local authorities
that include the Scottish Executive Education and Health Departments, the
Convention of Scottish Local Authorities, Learning and Teaching, Scotland, NHS
Health Scotland, Her Majesty’s Inspectorate of Education and the National Health
Promoting Schools Network. Importantly, these partnerships signal high policy level
collaboration between the education and health sectors. The Being Well – Achieving
Well approach has highlighted the fact that
for the first time, education legislation recognises that pupils have educational rights
and must be seen as partners in the school. The Act (2002) makes it clear that every
child has the right to receive a school education. The Act also sets out a framework
for improvement within which there is a duty on education authorities to provide
school education directed at developing the personality, talents and mental and
physical abilities of the child or young person to their fullest potential (p.4).
The Achieving Well – Doing Well document has pointed out the diversity of national
and local policy initiatives under which HPS has been developed with the challenge
being for strategic planners in the various sectors mentioned in the previous paragraph
to “create an integrated implementation strategy that takes account of the full range of
policy initiatives and yet has within it a clearly defined element that will ensure that
schools develop and can be recognised as HPS” (p.15). The areas for strategic
development of HPS in Scotland have been identified as: (1) community planning and
the integrated delivery of services; (2) building on current progress in the
development of HPS; (3) extending the concept of effective education; (4) developing
integrated community schools; and (5) staff development. In order to assist the
development of HPS within a broader policy framework, the Scottish HPS Unit has
been established by the Scottish Executive. This network comprises a member from
every local authority and National Health Service board in Scotland. A national
website has been established at www.healthpromotingschools.co.uk. One of the
Canada
Health promoting schools initiatives in Canada are based around the Comprehensive
School Health (CSH) Model (Johnston, 1999). A key component of the CSH is the
Student Health Model, which is a strategic systems approach to assist schools and
school boards in their implementation of the CSH. Specifically, the aim of the Student
Health Model is to “create students who are healthier, and thus learn better”
(Johnston, 1999).
The advancement of school-based mental health has been a significant focus across
the USA, particularly over the last decade. A 2002 state survey of school-based health
centre initiatives found that there were 1498 centres in 43 states of the USA (The
Center for Health and Health Care in Schools, 2002). Of the 30 states that reported
encouraging or supporting school-based health centres, nutrition was cited as the most
important prevention-related topic.
However, recent predictions of where the field of mental health in schools is going
have indicated that the field is in a state of flux (UCLA School Mental Health Project,
2004). While there appears to be no specific perspective or agenda dominating policy,
practice, research and training, the emerging view is that there is a need for “more
than expanded services and full service for schools” (p.8). The emerging view calls
for “enhancing strategic collaborations to develop comprehensive approaches that
strengthen students, families, schools, and neighbourhoods and doing so in ways that
maximise learning, caring and wellbeing” (UCLA School Mental Health Project,
2004, p.8). It has also been recognised that schools show less enthusiasm for
advancing school-based mental health when the focus is on mental disorders and the
emphasis for schools is to educate students. What is proposed is a systemic approach,
whereby changes can weave school resources with community resources to develop
• promoting the wellbeing of staff so that they can do more to promote the
wellbeing of students;
• fostering staff and student resilience;
• creating an atmosphere that encourages mutual support, caring and sense of
community;
• fostering smooth transitions, positive informal encounters, and social
interactions;
• facilitating social support;
• providing opportunities for ready access to information and for learning how
to function effectively in the school culture;
• encouraging involvement in decision-making; and
• welcoming and supporting staff, students and families at school every day as
an integral part of creating a mentally healthy school.
Access to resources to advance school based mental health has been challenging and
the current focus is on rethinking the ways in which existing resources can be
redeployed and by “taking advantage of the natural opportunities at schools for
encountering psychosocial and mental health problems and promoting personal and
social growth” (p.8). Key drivers at a political level for advancing school-based
mental health in the US are the mandates of No Child Left Behind Act and the
Individuals with Disabilities Education Act and the recommendations of the
President’s New Freedom Commission on Mental Health. The proposed model for
advancing mental health in schools incorporates mental health into the core business
of schools with the need to ensure that a full continuum of promotion, prevention and
early intervention and systems of care are implemented. This continuum is illustrated
below (Figure 3):
Systems of Care
treatment/indicated
interventions for severe and
chronic problems (High end
need/high cost per individual
programmes)
(Alderman, 2004)
Emerging approaches have also resulted in the development of a new group called the
School Mental Health Alliance. This alliance developed the following statement to
build consensus, with the statement being endorsed by over 20 key organizations that
represent education, health and mental health:
Australia
In Australia HPS has been implemented in most states. However, the significant
national focus has been on the development and implementation of the MindMatters
Project in secondary schools. This focus has largely been determined by findings that
have highlighted significant mental health concerns among young people such as
anxiety, depression, conduct and behavioural concerns, psychosis, drug and alcohol
related concerns, suicidal behaviour and suicide. The Australian National Mental
Health Strategy also highlighted the issue of stigma in relation to mental ill health.
MindMatters - Australia
The national MindMatters Project implemented throughout Australia is currently
being conducted in collaboration with the Australian Principals Associations
Professional Development Council (APAPDC) www.apapdc.edu.au and Curriculum
Corporation (CC) www.curriculum.edu.au and is funded by the Commonwealth
Department of Health and Ageing www.mentalhealth.gov.au. The uptake of the
MindMatters Project across Australia has been considerable. As of November 2003,
68 percent (1894) of Australian secondary schools have been involved in
MindMatters professional development with over 31,928 people (teachers, principals,
indigenous workers, community service providers) whereas in 2001 sixty school staff
participated in whole school professional development compared with 6,000 during
2003.
Who is Level of
involved intervention
Figure 4: The World Health Organisations’ Whole School Approach to School Change
MindMatters Plus
This component of MindMatters builds on and operates within the already established
whole school framework. The focus of MindMatters Plus the improvement of mental
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 34
health outcomes for students with high support needs through the implementation of
evidence based prevention and early intervention programmes. The Australian
Guidance and Counselling Association (AGCA) are currently managing this
component. AGCA supports schools to make links with appropriate services, thus
increasing the local infrastructure to support more vulnerable students’ mental and
emotional wellbeing. Information on MindMatters Plus is available on the
MindMatters website http://www.curriculum.edu.au/mindmatters.
FamiliesMatter
This initiative is currently being developed and aims to engage parents in the
MindMatters Project. The project began in June 2002 and has involved a series of
focus groups nationwide with a total of 83 parents currently involved in the
development of a parent resource package. FamiliesMatter is currently being trialled
in 15 MindMatters Plus schools from each state with the aim being to implement the
strategy in 300-400 MindMatters schools across Australia.
A recent case study highlighted the following components as being critical to the
implementation of MindMatters (Hazell, O'Neill, Vincent, Robson, & Greenhalgh,
2004):
Therefore, the approach the project team adopted in working with schools was to
explore the ways in which the conceptual and operational frameworks of the
Gatehouse Project could provide added value to what schools were already doing. The
conceptual framework emphasised the importance of healthy attachments and positive
connections among teachers and peers. The three areas of action that were identified
are: building a sense of security and trust; (2) enhancing communication and social
connectedness; and (3) building a sense of positive regard through valued
participation in aspects of school life.
Secondly, the Gatehouse Project also utilised the HPS framework, which is referred to
as the projects ‘operational framework’ to establish a whole school approach that
“introduces relevant and important skills through the curriculum; makes changes in
the schools’ social and learning environments; and strengthens links between the
school and its community http://www.rch.org.au/gatehouseproject/. The two arms of
the project embrace both an individual-focused approach in the context of supportive
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 36
classroom environments and an environment-focused approach that aimed to address
the protective and risk factors in the school environment. Figure five below, provides
a conceptual model for the Gatehouse Project (Patton et al., 2003).
The Gatehouse Project has also adopted an evidence-based process for planning,
implementing and evaluating a practical initiative, which included both individual-
focused and environment-focused approaches to change. This process is outlined in
numerous health promoting schools resources worldwide and includes the five
process steps of: (1) establishing health teams of staff and students; (2) reviewing
policies, programmes and practices to identify priority areas for action; (3) planning
strategies to address identified areas; (4) training and implementation: and (5)
monitoring and evaluation (Bennett & Dickinson, 1997; Brunn Jensen & Simovska,
2002; Butler, Bond, Glover, & Patton, 2002; Dickinson, 2001; Patton et al., 2000;
Public Health Promotion & Mental Health Foundation, 2001).
The Gatehouse Project team conducted a survey which provided schools with data
specifically relating to “students’ perceptions of the school’s social and learning
environments, with the data being arranged to provide information on peer
relationships, teacher –student relationships, and relationships with learning and
schooling in general” (Bond et al., 2001, p.373). The resulting profile presented to the
project schools indicated the protective and risk factors in the school environment.
Learning and health go hand in hand. Good health of children and young people is a
prerequisite for educational achievement. Good health of teachers is important to the
development of effective schools. Health promoting schools aim at empowering
students, staff and parents to actively influence their lives and their living conditions
(European Conference, 2002).
It is readily acknowledged that children and young people experience more positive
learning and achievement outcomes when they are well nourished, engage in regular
physical activity and experience school as a caring supportive social and learning
environment. This section highlights evidence from international studies that
demonstrate these links to learning and achievement and wellbeing. Nutrition and
physical activity are the two key factors stated in the recently signed tripartite
agreement in Aotearoa/New Zealand between the Ministries of Health and Education
and Sport and Recreation. However, given the holistic model of health that is the
focus of health promoting schools in Aotearoa/New Zealand, mental, social,
emotional and spiritual wellbeing are very much an integral part of this equation.
Schools have been viewed as an ideal setting or entry point for health sector targeting
of research and initiatives that focus on the promotion of mental, emotional and social
wellbeing and the prevention of mental illness. As with many other health promotion
initiatives, the initial focus has been driven from an illness perspective with the focus
being on addressing risk factors rather than an educational or health promotion
perspective (Rowling & Gehrig, 1998). Increasingly, evidence suggests that the
education sector has a crucial role in promoting and supporting mental health due to
More recently, Weare (2000) has pointed out that significant changes in the status of
mental, emotional and social health have been occurring due to emerging evidence
from research and practice that demonstrates “the importance of this issue in new and
dynamic ways, creating a new interest in social and affective health in schools” (p.2).
Weare (2000) has provided several reasons for this shift in focus:
• the new biology which recognises the importance of emotions and the need to
manage them;
• the breakdown of social structures;
• increased pressure on children and young people;
• effective schools affect mental, emotional and social health;
• intelligence is ‘multiple’ and can be emotional and social;
• new demands on teachers with regard to pressures on young people that can
make them difficult to engage in learning and the increasing pressure for
teachers to perform; and
• mental, emotional and social health as the ‘missing piece’ and the generic key
to addressing more detailed educational and social concerns (Elias et al., 1997;
Weissberg, Jackson, & Shriver, 1995).
Reflecting the view of many researchers in the fields of health and education are these
words from researchers Hargreaves, Earl and Ryan (1996) who have pointed out that:
“one of the most fundamental reforms needed in secondary or high school education
is to make schools into better communities of caring and support for young people
(p.77). Osterman (2000) has stated, the concept of experiencing a ‘sense of belonging’
is one of the most commonly stated factors in definitions of ‘community’ in the
literature. She has cited the work of McMillan and Chavis (1986) as providing the
guiding perspective and definition for her work on ‘’belonging’ in the school
community. Specifically, these authors have defined ‘community’ in two ways: (1)
community is a geographical unit; and (2) community is relational and describes the
quality of interpersonal relationships. As well, four components are integral to
McMillan and Chavis’s definition of community: (1) being a member of the
community; (2) experiencing influence within the community; (3) being integrated
within the community; and (4) sharing emotional connections within the community.
In a review which included over 300 citations, authors Baumeister and Leary (1995)
found that a sense of belonging was associated with: (1) perceiving friends and peers
more positively; and (2) experiencing more positive emotions (e.g., happiness,
calmness, contentment) which contributed to feeling accepted, included and
welcomed. In contrast, a wide range of mental health and behavioural concerns (e.g.,
anxiety, depression, suicidal ideation, violence, substance misuse and sexual activity)
were found to be associated with a lack of belongingness. According to Osterman
(2000) “being part of a supportive network reduces stress, whereas being deprived of
stable and supportive relationships has far-reaching negative consequences” (p.327).
Research has indicated that schools’ can be proactive in developing a positive school
climate by attending to: (1) enhancing the quality of life at school and especially in
the classroom for students and staff; (2) pursuing both academic and social and
emotional learning; (3) enabling teachers and other staff to be effective with a wide
range of students; and (4) fostering motivation for learning and teaching (Samdal et
al., 1998). To achieve this, school climate research literature has advocated for:
The most common factors associated with children and young people liking school
were experiencing: school as a nice place to be; a sense of belonging at school; fair
Findings from the Health in Schools Survey (392 young people from 41 secondary
schools in London) invited young people to express what they felt the priorities
should be in creating healthier schools (Healey, 2002). Three issues emerged as key
concerns: the quality, price and appropriateness of school food; the lack of provision
of regular enjoyable exercise; and the problem of bullying (p.3).
Social inclusiveness
Social inclusiveness, which is not dissimilar to belonging and connectedness, has also
been identified as a critical factor for positive mental health (Weare & Gray, 2003).
Research conducted by (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2002) has
provided evidence that initiatives that focus on positive behaviour management and
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 46
enable young people to resist negative social influences and avoid trouble are
effective. Their long term evaluation of 800 young people who participated in the
Seattle Social Development Project indicated that post programme young people were
less likely to engage in criminal acts, were less violent and were less likely to
participate in alcohol misuse.
In contrast, a study conducted by researchers Maes and Lievens (2003) found that
young people who truanted from school were more likely to be alienated and
experienced poor academic achievement. Those young people who were alienated
from school were also more likely to engage in smoking and drinking alcohol.
Findings from this study also indicated that there were individual characteristics
associated with young people who truanted and repeated classes as well as school
climate characteristics, which indicated that “some schools seem not to be able to
provide “meaning” and a sense of belonging for the pupils,” (p.525).
One explanation provided by Elias and colleagues (1997) is that when people are
overwhelmed by powerful negative or distressing emotions they are not able to think
clearly. A recent review of a range of educational studies indicated that the
achievement of academic goals was complemented by a focus on emotional wellbeing
rather than being in conflict with them (Weare, 2000). Conclusions drawn from these
study findings were that four key elements were essential if schools were to be
effective in both learning and achievement and affective domains:
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 47
• supportive relationships, especially understanding, helpful and friendly
teachers;
• a high level of participation in school life by staff and students, particularly
where schools had a strong sense of community, the whole staff were engaged,
communication was open and participatory decision-making processes
involving staff and students;
• the encouragement of autonomy among staff and students whereby the school
promoted independent learning and where teachers had a degree of control
over their own work; and
• clear rules, boundaries and expectations such as everyone in the school and
surrounding community understood their role and the norms, values and
expectations of the school (Weare, 2000).
Each of these four key elements, individually, have been found to be associated with
improved academic success, students being more engaged in their learning, greater
retention at school, more competent teaching, improved social competence and
morale and less absenteeism. Together, these four elements are even more effective
(Weare, 2000). When children and young people gain social and emotional skills, they
experience educational gains, which include improved school attendance, higher
motivation and higher morale (Durlak & Wells, 1997).
Weare and Gray (2003) have also explored research relating to the way in which the
brain operates under different conditions. For example, findings indicated that
individuals need to experience positive emotions in order to learn effectively.
Likewise when a person is experiencing considerable stress, the brain reverts to more
primitive survival needs. This sense of stress can be the result of personal or
environmental threat such as witnessing violence or being bullied or within the
classroom environment such as a student struggling with a task set by the teacher.
These authors have suggested that emotions constitute part of higher order thinking
and therefore require people to think about emotions, organise them, modulate them,
moderate them and shape them through reflection and learning, rather than simply
responding reactively or blindly to different emotions.
Similarly, the Gatehouse Project found that the most immediate priority for schools
was to address concerns relating to bullying and harassment among students. This was
due to findings from the Gatehouse Project Adolescent Health Survey of Year 8
students during 1997, whereby fifty-three percent of students in their first year of
secondary school reported that they had recently been victimised in some form at
school and 16% indicated that this occurred for them on a daily basis. Of significance
was the impact of this behaviour on the mental health of young people with those who
reported being victimised being three times as likely to be at risk of having depressive
symptoms (Bond et al., 2004; Butler et al., 2002; Patton et al., 2000).
Young people who were more likely to experience being bullied had difficulty
making friends, felt helpless, lacked confidence, were less likely to be happy and
often felt depressed. Similarly, findings from a study conducted by Natvig and
colleagues (2003) indicated that those young people who experienced a number of
school related stressors such as feeling alienated, being bullied, putdown and harassed
were unhappier than those who reported experiencing positive social support from
peers and teachers. Healey’s (2002) study, found that of the 392 young people
surveyed, more than half of them had experienced bullying and one in five young
Recent research in Aotearoa/New Zealand has also indicated that being bullied at
school correlates with anxiety and depression (Coggan et al., 2003). Findings from a
recent New Zealand school-based study indicated that many young people considered
that their schools did not treat the issue of bullying seriously enough (Trenwith,
2001). Carr (2000) in his comprehensive review of effective programmes to counter
bullying in schools found that a whole school approach was essential in addressing
this concern. The most effective classroom approaches were the promotion of social
and emotional competencies. He maintained that the key factors that contributed to
addressing bullying behaviour were:
Another study reported that children who experienced teasing about their weight were
more likely to have poor body image, low self-esteem, and symptoms of depression
(Janssen, Craig, Boyce, & Pickett, 2004). Additionally, findings have indicated that
26 percent of adolescents who were teased at school and home reported they had
considered suicide and nine percent had attempted suicide (Source: Archives of
Paediatrics and Adolescent Medicine, “Associations of Weight-Based Teasing and
Emotional Wellbeing Among Adolescents” August, 2003). Various researchers
(Alfermann & Stoll, 2000; Hagger, Chatzisarantis, & Biddle, 2001) have also found
that there are associations between self-concept and physical activity, with children
and young people with a strong self-concept being more likely to engage in physical
activity . However the direction of this relationship remains unclear. Park (2003)
reviewed data from Statistics Canada’s National Population Health Survey (1994/95
to 2000/2001), which followed young people who were aged 12 to 19 in 1994/95 to
2000/01 when they were aged 18 to 25 years. Findings indicated that low self-concept
was related to depression, physical activity and obesity in young adulthood,
particularly for girls. In contrast young people with a strong self-concept were more
likely to experience positive mental health. Park has also suggested that
while parents, educators and practitioners are undoubtedly aware of the immediate
effects of adolescent self-concept, they may be less cognizant of the longer-term
effects. Moreover, given such consequences, health promotion policies and health
education programmes might benefit from including mechanisms to enhance
adolescent self-esteem and mastery (Park, 2003, p.49).
In summary the literature reviewed has indicated that there are associations between
positive learning and achievement outcomes when children and young people are well
nourished, engage in regular activity and experience school as a caring supportive,
social and learning environment. As well, being connected to school, being treated
fairly, and learning in a positive supportive classroom environment all create positive
conditions for wellbeing. Key factors that contribute to a healthy school environment
and the development of emotional competence in children and young people are: the
commitment of senior school managers; a school culture that values children and
young people; clear policies and practices; skilful teaching; a high level of
participation in school life by staff and students; and supportive relationships.
The literature reviewed has also highlighted the issue of bullying and harassment as
being endemic internationally and nationally. This issue has been considered a high
priority for schools to address due to the serious impact that this behaviour has been
found to have on the mental, emotional and physical wellbeing of children and young
people.
Evaluating the health promoting school and its effectiveness is crucial to its future
development and sustainability. The research needs to be sound, relevant, respond to
the full array of elements, which constitute HPS and satisfy the criterion of utility
(Stears and Parsons, cited in Weare, 2002, p.9).
In recent years there has been considerable debate as to the ways in which HPS can be
evaluated and monitored (Nutbeam, 1998). It is readily acknowledged that HPS is
ecological in nature, complex, multisectoral and long-term. Therefore, it is essential
that evaluations aim to capture these characteristics (Stears & Parsons, cited in Weare,
2002, p.9). Due to the many different levels of HPS and the value factors inherent in
community development approaches, evaluation is particularly challenging. Rather
than the rather ambitious focus on achieving short-term specific health outcomes,
consideration of the ways in which health-promoting school initiatives involve the
process of enabling or empowering individuals or communities is an important
criterion (Stears & Parsons, 2002, cited in Weare, 2002, p.9).
The current emphasis on the need for evidence-based practice has highlighted the
complexities of “determining what is acceptable as evidence in the context of HPS,
and what are the most appropriate methods for collecting this evidence (Rowling &
Jeffreys, 2000, p.117). One such complexity highlighted by these authors is that
there are different interest groups at work with the HPS approach in Australia, each
with varying sets of concepts and principles as to what constitutes effective health
promotion in schools, and thus what makes for appropriate evaluation criteria and
processes (Rowling & Jeffreys, p.118).
Importantly, they have argued that evaluation needs to involve: monitoring decisions
made, the decision making process and the changes that occurred; and having a
These authors have concluded that the monitoring of good heath promotion practice in
school and community settings needs to be acknowledged as an “indirect or
intermediate indicator of heath outcomes and an essential and legitimate form of
evidence” (p.123).
Van den Broucke (cited in Weare, 2002, p.8) has provided a list of tools for
evaluation HPS that have been tried and tested:
In summary, the literature reviewed has suggested that criteria for effectiveness of
HPS evaluation encompass the capturing of processes, decisions made and outcomes
achieved. The long-term nature of HPS means that care must be taken by those
evaluating HPS to create realistic evaluation aims rather than a sole focus on trying to
assess health outcomes in the short term.
This section provides a brief overview of two tools that have been developed and used
internationally that enable schools to focus on assessing their current policies and
practices and the way in which these support the wellbeing of staff and students.
These tools can be adapted for consultation, needs analysis and evaluation purposes.
The tools included are: (1) the psycho-social environment profile (PSE); and (2)
examples of MindMatters tools which assess school organisation, ethos and
environment, students opinions and experiences of school, and SchoolMatters whole
school audit. Each of the tools has been included in the Appendices to this report.
The PSE has been developed as a tool to assist teachers, students and parents in the
creation of a positive psychosocial environment in their school. The questions are
designed to explore: the importance of a healthy psychosocial environment; identify
positive characteristics of a school’s environment and which characteristics can be
amenable to change. The issues addressed in the PSE Profile (Appendix Two) are
common to many schools globally and the WHO recommends that the profile be used
as is rather than deleting or changing parts. While the PSE Profile is not designed for
Health Promoting Schools: A review of international literature and models of practice
Pauline Dickinson, May 2005
Page 57
students, it is important that students are involved in discussions about the findings.
Children and young people should also be included in the implementation of any
changes. The items in the PSE Profile Questionnaire were developed largely from a
systematic review of evidence from over 650 research articles in the international
literature. Schools in 20 countries then reviewed the profile. The profile assesses
seven quality areas, each representing an aspect of a healthy psychosocial school
environment:
In summary there are a number of tools that have been developed internationally that
can be used to assess schools’ social environments. These tools are available for use
and can be adapted for use within primary and secondary schools.
Internationally, innovative initiatives have been developed to promote and support the
wellbeing of children and young people in school and community settings. Global
initiatives have signalled the need to prioritise mental, emotional and social wellbeing,
nutrition and physical activity. This is due to research findings that have indicated that
children and young people are better able to learn, achieve and develop socially
within the context of a safe, supportive and quality teaching and learning school
environment.
Internationally, school health initiatives that have been developed and implemented
through health and education sector collaboration and partnerships at a government
policy level. Throughout Europe, the European Network of Health Promoting Schools
has provided a platform for the coordination and sharing of effective practices among
the schools involved. As well, many of these schools are involved in the World Health
Organisation’s Child Health Behaviour survey mentioned earlier in this report.
While the international literature reviewed for this report lacked a focus on indigenous
HPS initiatives, this is not to say this work does not exist. One possible explanation is
that this work may not have been documented in the types of literature reviewed for
this report. In Aotearoa/New Zealand the establishment of a Maori specific focus
through a strategic planning positon and Maori practitioner workforce in the Auckland
region and the development of a Maori HPS resource has provided a developing
model of practice that could be adopted nationally over time.
The international literature reviewed has indicated that there is a wealth of innovative
HPS work which has gained momentum through promising models of practice that
are ecologically based and focus on building supportive school social and learning
environments. Given that positive learning and achievement experiences and
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