Health Promotion and Health Education in Schools Trends, Effectiveness and Possibilities

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1 Health Promotion and Health Education in Schools Trends, Effectiveness and Possibilities June 2006 Research report 06/02

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3 Royal Automobile Club of Victoria (RACV) Ltd RETRIEVAL INFORMATION Report No. Date ISBN Pages PP 06/02 June Title Health Promotion and Health Education in Schools Trends, Effectiveness and Possibilities Author Associate Professor Lawrence St Leger Performing Organisation Royal Automobile Club of Victoria (RACV) ltd 550 Princes Highway Noble Park North VIC 3147 Abstract Health promotion and health education activities occur in all Victorian schools. Despite this, there is some considerable uncertainty about whether the efforts of schools and health promotion agencies including organisations responsible for Traffic Safety Education (TSE), achieve the desired outcomes. The long held belief that if young people receive basic knowledge about a health issue, then they will adopt appropriate health enhancing behaviours is theoretically flawed. This report involved an extensive literature review as well as discussions with ten leading school health and traffic safety education researchers and practitioners. The findings of the report show that despite health promotion and health education activities occurring in all Victorian schools, school health related initiatives could be improved by focussing on cognitive outcomes and involving appropriate components of Health Promoting School (HPS) framework. Providing teachers with professional development and utilising interactive resources that complement the curriculum is also important. The report recommendations outline ways to improve the Health Promotion and Health Education and provide a potential framework for delivering TSE provision in schools. Keywords School; Education; Health; Road Safety Education; Health; Driver Education; Australia; International Comparison; Survey; Evaluation; Child; Young Person; Adolescent; Health Promoting School (HPS); Cost Benefit Analysis Disclaimer The research presented in this Report has been funded by RACV and is released in the public interest. The views expressed and recommendations made are those of the authors and do not necessarily reflect RACV policy. Although the Report is believed to be correct at the time of publication, RACV, to the extent lawful, excludes all liability for loss (whether arising under contract, tort, statute or otherwise) arising from the contents of the Report or from its use. Where such liability cannot be excluded, it is reduced to the full extent lawful. Discretion and judgement should be applied when using or applying any of the information contained within the Report. REPRODUCTION OF THIS PAGE IS AUTHORISED HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES i

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5 Executive Summary Health promotion and health education activities occur in all Victorian schools. In fact, addressing health issues has been a part of school programs for over 100 years. However, there is some considerable uncertainty about whether the efforts of schools and health promotion agencies who use schools as sites for their interventions, achieve the desired outcomes. There has been a clearly held belief that if young people (5-18 years) receive basic knowledge about a health issue, they will adopt appropriate health enhancing behaviours. Most school health programs, projects and packages were designed based on this belief. However, research in the last 20 years suggests that the provision of information will lead to behaviour change approach is theoretically flawed. The literature indicates that schools can make a difference to the health knowledge, competencies and, in some cases, the health status of students, but these outcomes are small. There is also considerable debate about the role of schools in achieving health outcomes where their core business is the attainment of educational outcomes. Should schools be asked to solve societal health issues, e.g. drug misuse, obesity, depression, sedentary behaviour, etc? This report identified the main conditions for effective school-based health promotion and health education interventions. It showed that schools can be reasonably effective in their health related initiatives if their programs are: Focussed on cognitive outcomes as a priority over behaviour change Comprehensive and involve appropriate components of the Health Promoting School (HPS) framework Substantial, preferably over several years, and relevant to changes in young people s social and cognitive development Enabling teachers to gain new knowledge and skills through professional development Using resources which are engaging and interactive and which are complementary to the work of teachers. The potential of the Health Promoting School (HPS) is examined. This model of school health emerged over 15 years ago as a more effective way to address health issues. The HPS is mapped in three perspectives - health, education and traffic safety. From these frameworks opportunities emerge which will mean traffic safety organisations can be more strategic and effective in what they can reasonably expect of schools in traffic safety education. Recent literature on traffic safety school-linked programs was examined. Although this review was about the factors which make school health initiatives effective or not, it was important to understand why traffic safety programs work or do not work. The general findings of the analysis were put to nine international experts in school health promotion and education, and one international expert in traffic safety education for their reactions. In general, they believed: School health promotion and education should be supportive of, and connected with, the achievement of educational goals and not as independent interventions which seek to address a societal health issue Health and related organisations should use the substantial body of evidence about how students learn and what constitutes good schooling before embarking on their interventions HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES iii

6 Ongoing and substantial professional development for teachers is fundamental to achieving the objectives of the health intervention Participatory learning with a focus on students addressing health related issues (including traffic safety) in ways that empowers their health literacy and activism is necessary to achieve both health and educational outcomes. From the evidence of effective school health and traffic safety programs, a set of recommended actions are proposed. These are: Recommendation 1 Ongoing actions for traffic calming should be a high priority for neighbourhoods containing schools, particularly primary schools. Road safety agencies should actively raise awareness, advocate and facilitate links between school councils and the main authorities, e.g. education systems, local government, and police to ensure the risk of traffic crashes is reduced around schools. Recommendation 2 Traffic safety and related issues be integrated into school activities with a focus on enhancing educational outcomes. Recommendation 3 Students from the age of years should be empowered to be traffic safety advocates through curriculum integrated initiatives which build their knowledge and skills on local traffic issues which are amenable to action. Recommendation 4 Students from the age of years should be provided with opportunities to learn about the culture and responsibilities of car use. Relevant components of the senior curriculum should be enriched with traffic/car related issues which extend and challenge the student s appreciation of traffic and car use. Recommendation 5 All school-based traffic safety activities should use the Health Promoting School (HPS) framework as a template for action. The Structure of the Report This report outlines what schools can reasonably achieve in school health promotion and education initiatives. It begins by looking at what health promotion is and how it has developed. The paper then explores the effectiveness of health promotion actions and what constitutes evidence of effectiveness. Schools are the most convenient setting to access large groups of young people. But what do schools actually do in health promotion and what are their levels of effectiveness in improving health outcomes? And why is it that health interventions promoting change works in schools and what makes them a failure? The reasons for the shape of school health today are explored by identifying the major impacts on school health development in the last 100 years. (Section 3) A new and more promising model of school health Health Promoting School (HPS) is examined in Section 4. Section 5 provides ideas about how the Health (and other sectors) can link with the Education sector using the HPS as a framework. How does one measure the success of school health interventions? What does the evidence tell us about effective school health promotion initiatives? Sections 7 and 8 examine these two questions. The main resource in a school is the teacher. Section 9 briefly describes the evidence of why teachers will embrace (or ignore) an externally created initiative. It also identifies what it is about schools that enable changes, such as traffic safety programs and actions to be adopted, implemented and sustained. iv RACV RESEARCH REPORT NO 06/02

7 Section 10 provides a brief summary of meta-analyses and other literature about the effectiveness, or not, of traffic safety education initiatives. A set of realistic scenarios for traffic safety are proposed in Section 11 based on the evidence from this section and the others. Ten international experts in school health promotion and health education and school traffic safety were contacted and asked about their ideas for the future of school-based traffic safety initiatives. Section 12 provides a summary of their reactions. Finally, Section 13 contains Recommendations for road safety organisations to consider which, it is argued, are based on the best available evidence and advice at this time. These Recommendations focus on Traffic Safety Health Promotion using the school as a setting. HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES v

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9 Table of Contents 1. The Origins and Components of Health Promotion The Beginnings Ecological Health An Integrated Approach The Principles of Health Promotion The Ottawa Charter for Health Promotion The Strategies and Practices of Health Promotion 5 2. Effective Health Promotion Questions of Evidence Outcomes for Health Promotion Actions Traffic Safety and the Outcomes Model 6 3. The development & changing nature of health in Victorian schools The Early Years Creating a Health Curriculum Developments in the Last 25 Years The Hobart Declaration on Education The Health Promoting School (HPS) The Origins of the Health Promoting School The Structure of the Health Promoting School Benefits of the Health Promoting School Australian and International Support for the Health Promoting School Linking the health, education and other sectors to improve school health Assessing school health interventions Health Indicators and Schools Effective school health promotion The Main Purpose of School Health What Works in School Health Promotion What Does Not Work in School Health Promotion School-based health promotion in Australia and Victoria Schools, teachers and change The Challenges of Change in Schools Individuality to Collegiality A Necessary Condition for more 29 Effective School Health HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES vii

10 10. Schools and traffic safety The Major Findings from School Connected Traffic Safety Research Determinants Physical Environment Traffic Safety Behaviour of Children Traffic Safety Clubs Traffic Skill Training for Children Parental Involvement Costs and Benefits Interventions The health promoting school and traffic safety Scenarios for Future Action What the experts say Recommendations References 40 List of tables and figures Table 1 Examples of Actions within The Ottawa Charter Framework Table 2.1 An Outcome Model for Health Promotion Table 2.2 An Outcome Model for School-Based Traffic Safety Initiatives Figure 1 The Mandala of Health Figure 2 Australian Institute of Health & Welfare (AIHW) Health Framework Figure 3 Health Perspective Figure 4 Education Perspective Figure 5 Traffic Safety Perspective viii RACV RESEARCH REPORT NO 06/02

11 1. The Origins and Components of Health Promotion 1.1 The Beginnings Health Promotion emerged in the 1980 s as a way of addressing health issues in an integrated way. It is multi-disciplinary, drawing on fields such as psychology, biology, sociology, economics, political science, medicine, and law. It developed as a response to a significant body of research which suggested that it was more effective to look at the contexts in which people lived, rather than only addressing their behaviours. Hancock and Perkins (1985) developed models to identify those factors which impacted on our lives. See Figure 1. Figure 1. The Mandela of Health (Adapted from Hancock & Perkins, 1985) Culture Community Lifestyle Personal behaviour Family Psycho-socio Economic development Spirit Medical system Body Mind Human biology Physical environment Human-made environment Biosphere The Australian Institute of Health and Welfare (AIHW, 2000) produced a framework which mapped the complex interplay between both individual and environmental factors. HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES 1

12 Figure 2. Australian Institute of Health & Welfare (AIHW) Framework (AIHW, 2000, pp.3-4). Determinants of Health Environmental Physical Chemical Biological Social Economic Cultural Political Individual Genetic contribution Attitudes and beliefs Lifestyle and behaviour Biomedical factors Health and wellbeing Disease Impairments Symptoms Injuries Disability (functional limitations) Interventions Prevention and health promotion Treatment and care Rehabilitation Resources Research Evaluation Monitoring Other Information Financial Material Human These factors can be modified to varying degrees by health promotion, protection, treatment and rehabilitation interventions. The model identified the necessary resources to support these interventions. Health Promotion is defined in a number of ways. For example, the World Health Organisation (1986) stated: Health promotion is the process of enabling people to increase control over, and to improve, their health. In their widely accepted book, Green and Kreuter (1991) suggested: Health promotion is any combination of health education and related organisation, economic and environmental supports for behaviour conducive to health and well-being. Whilst Raeburn and Rootman (1998) claimed: Health promotion is concerned with positive health and well-being; with the whole of life involving a complex notion of health to include bodily, mental, social and spiritual states and which (health promotion) occurs incrementally over time linked to everyday life and community and is about changing the balance of power in the human and health domains. 1.2 Ecological Health An Integrated Approach Ecological health emerged internationally during the 1980 s. However, for a number of populations it was how they currently viewed and practised health. Ecological health puts into practice an integrated approach supported by models such as the Mandala of Health which sees the person as being influenced by a number of factors. It reconnects people to their social and physical environments and takes account of their culture, history, family, community services and infrastructure such as transport, hospitals and schools. Kickbusch (1989) argued that we have developed considerable knowledge and skills in science and medicine to diagnose and treat disease. Also we have created a substantial knowledge base about why people behave in certain ways with respect to their health. These factors have caused us to focus largely on disease categories and risk factors such as high blood pressure, dietary fat, drug usage and cholesterol. This focus has been directed at the individual. It has moved away from the context of people s lives which is how many communities have historically viewed health. 2 RACV RESEARCH REPORT NO 06/02

13 Ecological health is directed at addressing the underlying social and community factors that influence health and well-being. It takes into account such aspects as housing, transport, community facilities, education, and welfare. It recognises that what is done in one country will have positive or negative influences on the people in another country, e.g. economic tariffs on exports and imports; pollution of the air; war and the associated problems of refugees. These and many other factors all affect the health of populations. Kickbusch (1989, p14) stated: An ecological approach moves health from an individual lifestyle/choice model to a broad gauged community issue. It starts with the basic and simple question: where is health created? The ecological answer in the language of everyday is: health is created where people live, love, work and play. It is created by human beings in their interactions with each other and with their physical environments. The consequence for a public health strategy is to commence from settings of everyday life within which health is created (rather than start with disease categories) and to begin with strengthening the health potential of the respective settings. This leads back to the theoretical notion of identifying patterns that constitute health and developing strategies that strengthen such patterns throughout the process of human development. The Ottawa Charter suggests that such patterns are strengthened by a public health strategy that accounts for five elements: An awareness of public policies and their health impacts A concern for social and physical environments supportive of health The need for personal skills development The importance of community involvement The need for public services to be responsive and oriented towards health. The ecological approach requires individuals and communities to develop strong networks which lead to actions to improve the health of their community and environment. If this occurs, individual health will be advantaged. 1.3 The Principles of Health Promotion Health Promotion is a relatively new area which seeks to enhance the health and well-being of population groups and their members. It is focused on preventing and/or reducing untimely morbidity and mortality. It is a way of mediating between people and their environment, combining personal choice with social responsibility, for people to create a healthier future. Health Promotion is practised in nearly all countries that are members of the United Nations. It occurs in many settings, e.g. schools, workplaces, hospitals, villages, towns, cities. Health Promotion includes: Working with people not on them Addressing all aspects of health (physical, mental, spiritual, etc.) Collaborating with the local community and their issues Addressing the underlying and immediate causes of health the determinants of health Working with both individuals and population groups Emphasising the positive aspects of health Being concerned with healthy lifestyles Incorporating all levels and sectors of society and the environment Emphasising partnerships and alliances between groups and sectors Building the capacity of people through education, training and work opportunities Being innovative and addressing challenges. HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES 3

14 1.4 The Ottawa Charter for Health Promotion The Ottawa Charter (WHO, 1986) identified three fundamental health promotion activities in implementing health promotion programs; these are advocating, enabling and mediating. The Charter, which adopted a settings approach, where the focus is on the settings in which people live, love, work and play, delineated five action areas for governments, NGO s, communities, private organisations and citizens. These action areas were: Building healthy public policy Creating supportive environment Strengthening community action Developing personal skills Reorienting health services. Examples of how the Ottawa Charter can be operationalised appear in Table 1. Table 1. Examples of Actions within the Ottawa Charter Framework 1. Build Healthy Public Policy 2. Create Supportive Environments 3. Strengthen Community Action 4. Develop Personal Skills 5. Reorient Health Services Smoke-free workplace policies Pool fencing laws No hat, no play policies in schools Bicycle helmet laws Improved safety requirements for cars Requirements for nutrition labelling on food products Reduced taxes on low-alcohol beer Drink drive laws Environmental protection laws and regulations Occupational health and safety laws Anti-bullying policies in schools and workplaces More bike paths Syringe disposal bins in public places Safe water supply Shaded areas in schools for play and sport Greater availability of low-fat, low-salt foods Alcohol-free dances for under 18s Access ramps for people in wheelchairs Social nonacceptance of smoking A community attitude that if you drink and drive, you re a bloody idiot Acceptance of talking publicly about sexual activity Peer education in the gay community Women s health groups Local environmental action groups Alcoholics Anonymous groups Breast cancer support groups Community walking groups Patient rights groups and consumer groups Organisation by youth groups of alcohol-free events Local action to establish alcoholfree Indigenous communities Young mothers groups Safe sex education in schools Pre-driver education Diabetes management education Cooking skills classes for older men Physical education classes Community education on slip, slop, slap Stress management programs Parenting courses QUIT courses Teaching of safe injecting techniques for intravenous drug use Incidental counselling by GPs about the risks of smoking or physical inactivity Breast cancer screening programs Brochures and information sheets on a range of health issues Multidisciplinary teams in health services Medicare Health promoting hospitals Divisions of General Practice contributing to community health education and promotion Primary Care Partnerships (PCPs) (Deakin University, 2003) 4 RACV RESEARCH REPORT NO 06/02

15 1.5 The Strategies and Practices of Health Promotion There are a number of approaches used in the promotion of health. These approaches are necessary to enhance the health of communities. The main strategies and practices of health promotion include: Awareness raising - Increasing the public and individual s knowledge of the issue, usually through media campaigns and publications e.g. speed awareness. Regulation and policies - Passing laws and developing policies to prevent health endangering practices (e.g. pesticides in food) and to promote good health (e.g. seat belt legislation, smoke free areas). Education - Equipping people of all ages with the knowledge and skills necessary to look after their own health and the health of others e.g. learning about disease transmission; skills in food purchase and preparation; skills in stress management; learning to drive a car safely. Advocacy - Enabling individuals and groups to lobby for changes which prevent ill health and promote opportunities for health to be advanced, e.g. lobbying for non-smoking work environments, vehicle safety. Mediation - Facilitating the balance between groups with differing interests in the pursuit of health, e.g. between the proponents of processed food and unprocessed food. Resources and services - The development of appropriate resources and services which enable people to access information and facilities which will enhance their health, e.g. electronic and print material to support drug management, telephone advisory services. HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES 5

16 2. Effective Health Promotion 2.1 Questions of Evidence Much has been written in the last five years about what constitutes evidence in health promotion. This is because there has been two decades worth of health promotion interventions in most countries around the world, on most health issues and involving many population groups and settings. The health promotion community have been able to identify a number of common elements about what constitutes evidence. They have also identified what is meant by effectiveness. Nutbeam (1999) argued that effective health promotion leads to changes in the determinants of health. There are many determinants of health. Some are within an individual s capacity to change, e.g. behaviour, use of facilities. Many, such as creating improved environmental, economic and social conditions, are outside individual control. Addressing these involves collective actions. Tensions arise sometimes between those providing financial support for health promotion interventions, the groups and individuals charged with implementing the intervention, and the population group to which the intervention is directed (Perkins, Simmett & Wright, 1999; Nutbeam, 1999). Different groups and individuals place different levels of importance on what should be measured. They also often have different interpretations as to what the evidence means. 2.2 Outcomes for Health Promotion Actions Nutbeam (1999) developed a framework to assist funders, policy makers, practitioners, researchers and target populations to better understand the variety of outcomes from a health promotion activity (see Table 2.1). Health and Social Outcomes are the end point of the actions. Intermediate Health Outcomes are the actual determinants of the Health and Social Outcomes which are amenable to modification. Health Promotion Outcomes represent those personal, social and structural factors that can be modified in order to change the determinants of health. Health Promotion Actions are the activities occurring in health promotion which are designed to produce certain health promotion outcomes, which modify the determinants of health to produce the required health and social outcomes. It becomes apparent from the table that many different evaluation methods and approaches are needed to assess the effectiveness of health promotion activities. The evaluation methods are determined by the intervention. They show us what works and why it works. Not all health promotion programs are worth evaluating. Scarce resources are often wasted in evaluating programs that do not meet the criteria for successful health promotion interventions. Nutbeam (1999) and Nutbeam and Harris (1998) found that successful health promotion interventions: are based on a thorough interrogation of the evidence from epidemiological, behavioural and social research are theoretically based according to the type of intervention create the conditions for successful implementation of the program; need to be of an appropriate size, of reasonable duration (3+ years) and complexity to be able to have a chance of success and to be amenable to evaluation. 2.3 Traffic Safety and the Outcomes Model Using Nutbeam s (1999) framework, a second table has been developed (Table 2.2). This focuses specifically on traffic safety and the population group of school students. This portrays the complexity of health promotion in action and provides a framework to make planning more strategic and interventions more effective. 6 RACV RESEARCH REPORT NO 06/02

17 Table 2.1 An Outcome Model for Health Promotion (Nutbeam, 1999) Health & Social Outcomes Social Outcomes measures include: quality of life, functional independence, equity Health Outcomes measures include: reduced morbidity, disability, avoidable mortality Intermediate Health Outcomes (modifiable determinants of health) Healthy lifestyles measures include: tobacco use, food choices, physical activity, alcohol and illicit drug use Effective health services measures include: provision of preventive services, access to and appropriateness of health services Healthy environments measures include: safe physical environment, supportive economic and social conditions, good food supply, restricted access to tobacco, alcohol Health Promotion Outcomes (intervention impact measures) Health literacy measures include: health-related knowledge, attitudes, motivation, behavioural intentions, personal skills, self-efficacy Social action and influence measures include: community participation, community empowerment, social norms, public opinion Healthy public policy and organisational practice measures include:policy statements, legislation, regulation, resource allocation, organisational practices Health Promotion Actions Education examples include: patient education, school education, broadcast media and print media communication Social mobilisation examples include: community development, group facilitation, technical advice Advocacy examples include: lobbying, political organisation and activism, overcoming bureaucratic inertia Table 2.2 An Outcome Model for School-Based Traffic Safety Initiatives (Nutbeam, 1999) Health & Social Outcomes Social Outcomes independence through using motor vehicles & public transport Health Outcomes reduced traffic crashes involving 5-18 year olds decreased deaths & disability rates in 5-18 year olds (decreased deaths & disability rates as adults *) Intermediate Health Outcomes Healthy lifestyles appropriate road safety practices Effective services adequate crossing supervision appropriate policing of traffic offenders near schools, e.g. fines Healthy environments safe crossing areas near schools Health Promotion Outcomes Health literacy skills in assessing traffic danger competencies in crossing roads ability to ride bikes safely Social action and influence community participation e.g. the walking school bus lobbying by local community for safer areas near schools lobbying by key groups to increase use of safety measures, e.g. side air bags, bicycle pathways, 120+ hours on L plates Healthy public policy and organisational practice policies within schools, e.g. no crossing of roads unless adequate supervision is provided policies with councils, e.g. all school crossings to be staffed by qualified people police supervision support available in terms of staff shortages P plate regulations Health Promotion Actions Education skills for young people in road management as pedestrians & cyclists competencies in learning to drive in different conditions Social mobilisation community awareness & participation on traffic issues, e.g. noise, speed, pollution safety Advocacy lobbying local councils, government representatives, etc. & officials to ensure the local school environment is safe for young people

18 3. The development & changing nature of health in Victorian schools School health today has been substantially influenced by school health of the past. This section provides a description of the major changes in school health for over a century. School health has always been part of a school s program. Yet it has invariably followed a crisis model based on poor health data (both morbidity & mortality) for young people. It is important to recognise why this has occurred and to examine the evolvement and development of school health in Victorian schools. 3.1 The Early Years The health sector was the dominant element in shaping school health in the last century. This trend continues in the 21 st Century. The commitment to school health in Victoria had its origins in the International Conference on the Health of School Children which was held in London in This international conference was the culmination of a number of Commissions of Inquiry during the latter part of the 19 th Century in many European countries. These commissions all recommended improving the health of school children through specific program interventions at school (Board of Education, 1910). Schools were seen as an easy access site. It was strongly held that knowledge transfer would change attitudes and practices. Australia took its lead in school education initiatives from Europe, in particular, England. Clement Dukes (1885) seminal work on school hygiene was used as the basis for planning Victoria s approach to school health. Mr Frank Tate, the Head of the Education Department, or the Director of Public Instruction as the position was known, was the first person to legitimise the importance of school health when he wrote a major article on the importance of hygiene in schools in 1906 in the Education Gazette. It placed health firmly on the agenda of school activities. Although permission for school health to occur emanated from the education sector, the actual implementation was directed and managed by the Medical Officers appointed to the School Medical Service. They wrote regular reports to the Minister of Public Instruction where they: bemoaned the health knowledge and skill of teachers It (health education) has been handicapped by the absence in a great majority of cases of the necessary knowledge. (Board of Education, 1911, p114). encouraged links between the school and community and with other curriculum areas More than any other subject it can serve to link up the home, school and communal life of the child it deals with matters that have a real relationship to his (sic) life and society it is capable of correlation to nature study, physical culture, first aid, domestic arts and morals. (Board of Education, 1913, p112). Schools devoted only 15 minutes per week to health which led the School Medical Officers to state: and we believe this is an appalling lack of time devoted to the pursuit of health in our schools. (Board of Education, 1914, p39). The main focus of school health was on alcohol reduction (it was then called Temperance Education ), physical activity (mainly for boys), moral education and basic hygiene practices. There was no attention given to sexuality, nutrition, traffic safety or drug education, other than alcohol. This scenario of a health sector dominance over the curriculum content, the limited professional development of teachers and the monitoring of the outcomes continued until well after the second world war. 8 RACV RESEARCH REPORT NO 06/02

19 3.2 Creating a Health Curriculum In 1961 the Chief Medical Officer of Victoria (Dr. Bertram McCloskey) and the Head of the Burwood Teachers College (Dr. Lawrie Shears, who was later to become Director of Education for Victoria) put forward a radical proposal for school health. The curriculum content was expanded to include new areas of safety, drug education and sexuality. Also, a set of guidelines for teachers was developed to assist them to teach health to primary and secondary students. The pilot program received a favourable evaluation report from the Australian Council for Educational Research (ACER) but ran into major difficulties which included: combined resistance by two teacher unions to adverse media coverage, particularly on television, which represented the health course as an official blanket over, in reality, sex education. (Sargeant, 1975, p22). The scientific evidence which showed the links between many personal behaviours and health, e.g. exercise, diet, safety practices, sexual behaviours, drug use, was well established by the 1960 s. A number of non-government organisations were created to address these issues in society. Organisations such as the National Heart Foundation (nutrition, physical activity, tobacco), the Anti Cancer Council (tobacco, sun protection), Alcohol and Drug Foundation (tobacco, alcohol, recreational drugs), and Family Life Movement (sexuality) were established in the early part of the latter half of the 20 th Century to promote health, act as lobby groups for health policies and as information clearing houses. They were joined by other groups such as RACV (traffic safety) and Dental Association (oral health) who also promoted aspects of prevention in their areas of interest. It was not surprising that as school health had been established for many years, yet lacked suitable resources for teachers and students, that many curriculum packages were developed by these organisations to assist schools to teach health. From the early 1970 s schools were bombarded with offers of kits, guidelines and visiting speaker services. Did it make any difference to the adoption and implementation by schools of the health issue? Did it increase student knowledge and healthy behaviours in the different health topic areas? These questions of effectiveness are explored later in Section 7 of this report. When Dr. Shears became Director General of Education he announced an enquiry into the school curriculum. The terms of reference (Education Department, 1973) identified six new curriculum fields which were proposed to be incorporated into the curriculum. They were: (a) pre-driver education (b) international education (c) work experience (d) health education (e) community education (f) human problems The final report did not identify a curriculum for school health, but suggested teachers needed more knowledge and skills to teach in these areas. 3.3 Developments in the Last 25 Years The focus on what should happen to the health curriculum in schools did not become clear until after the three further reports were produced in the late seventies and early eighties. Collectively, the reports played a major role in shaping the school health curriculum in Victoria in the last part of the 20 th Century. HEALTH PROMOTION AND HEALTH EDUCATION IN SCHOOLS TRENDS, EFFECTIVENESS AND POSSIBILITIES 9

20 (a) Report of health education study group to the council of the curriculum development centre (Curriculum Development Centre, 1977). The Curriculum Development Centre was a national body, which in partnership with the States, produced a number of frameworks and recommendations for school curricula in Australia. It considered that school health education programs, including those in Victoria, were inadequate, and made a number of recommendations. The key recommendations were that: 1. Health education programs be available to all students; 2. National, state and local governments work together in initiating and implementing programs in school health; 3. School health education programs should be supported by a school environment which is compatible with the physical, social and emotional bases of sound health education; 4. Health education be a separate discipline; 5. Teachers be provided with in-service support, syllabus guidelines, resources, materials and advisory services; 6. Tertiary institutions provide post-graduate training programs for teachers. (Curriculum Development Centre, 1977) (b) Report of health education in Victorian primary schools (Curriculum and Research Branch, 1977). Ninety-three percent of Victorian primary schools responded to a questionnaire on health education in Health education was second last on a list which sought to compare the time per week allocated to the different areas of the primary school curriculum. Where it was included in the curriculum, it was integrated with other areas in 82% of schools, and virtually had no identity of its own. The report concluded: the picture that emerges [about health education in primary schools] could only be regarded as disastrous [and] the understanding of the concept of health education is so limited in the majority of cases as to reduce the term to little more than a concern with general hygiene, neatness, and a sprinkling of safety education. (Curriculum and Research Branch, 1977, p12). However it was the next report which brought school health more into the public domain. (c) Guidelines on health and human relations education (Education Department, 1982) The Victorian Government developed a policy for the promotion of Health and Human Relations Education in Schools in It produced a set of Guidelines for Schools which suggested how schools could go about their school health initiatives, what might be included in the health curriculum and suggested outcomes for students. It left the content and implementation to individual schools and declared that the Principal and the School Council would be legally responsible, in that: The Principal of a state school shall be responsible for the establishment of a Health and Human Relations Committee in consultation and agreement with the School Council constituted under Section 13 of the Education Act of and indicated its functions as: Defining policy about health; Approving and delineating the rights of parents, students, staff and others; Considering and approving content and method; Establishing contact with and liaising with parents or community groups; Monitoring the progress and outcomes of programs. (Education Department, 1982, p. 9) 10 RACV RESEARCH REPORT NO 06/02

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