Successful implementation of a school health promotion program requires systematic planning and full engagement of target groups in order to inspire commitment, focus, and preparation to complete required tasks. Below follows an outline of the core elements of successful development and implementation of a school health promotion program.
The Development And Implementation Process
According to Fullan (1991, p. 65), implementation can be defined as ‘‘the processes of putting into practice an idea, a program, or a set of activities and structures, new to the people attempting or expected to change.’’ Implementation focuses on what happens in practice, and is concerned with the extent and nature of actual change, as well as the factors and processes that influence how and which changes are achieved (Fullan, 1991).
Four stages of implementation of programs have been identified (Green and Kreuter, 1999). The first stage addresses the motivation and role of the school leadership. As the leader of the school, the principal needs to make sure that the program is relevant to the school’s overall goals. Unless the principal and the rest of the school administration are convinced that the program is worthwhile, time and resources will be wasted and the program is unlikely to be fully or successfully implemented. In order to secure leadership motivation, schools should apply to participate, state their commitment to a minimum of 3 years for the implementation process, and describe how the project will be integrated in their school activities. A coordinator for the project should also be identified.
The second stage in the implementation process relates to formalization and institutionalization of the program. This means including the program in the school’s policy plan (or develop a policy or action plan if the school does not already have one), allocating time on the class and teacher schedules, and providing adequate resources and flexibility in the organization to facilitate necessary changes. Before formalization can take place, it is the responsibility of the principal to motivate and facilitate teachers’ participation in the program. Formalization of the initiative through allocation of time and resources demonstrates the school leadership’s motivation and priority and thus represents an important motivational factor for teachers’ commitment to the implementation of the initiative (Donaldson, 2001). Formalization becomes a way to set social norms among teachers.
In the health-promoting school approach, core elements of implementation are based on what the school aims to change or achieve. Identification of goals for change may be facilitated by use of a systematic planning tool suited to analyze both existing realities and developmental needs. The Precede-Proceed model developed by Green and Kreuter (1999) is such a tool. It focuses on the importance of identifying overall aims (what is to be achieved, and why this is important) before identifying actions that can meet the aims (how to achieve the aims). It is very important to allow adequate time for the planning phase to ensure that all needs are assessed and prioritized and to engage all participants. Survey tools and focus groups of students and staff may be useful in the needs assessment process. In addition, the identification of national forces and trends relevant to the local setting as well as national and international data on students’ health behaviors, health perceptions, and school satisfaction may constitute an important framework for identifying target areas. An example of such a data source is the European and North American Study of Health Behavior in School-Aged Children. A school may choose to address a problem or situation in a topic area where an effective program already exists. Use of a program with demonstrated efficacy may thus save valuable time and resources.
When the first and second steps of implementation have been achieved, this sets the stage for the third stepchange in teachers’ behavior and practice. These changes depend on the teachers’ motivation for and understanding of the initiative. The teachers will be the key implementers of the initiative for the students. Therefore their priority, conviction, and competence are vital to the initiative’s success.
The fourth and final stage involves change in student behavior, competencies, and experiences. Students’ change depends very much on how school administrators and teachers organize school and class activities. Moreover, much is gained when students are invited and trained to participate and claim a stake in school change.
All four stages involve a combination of bottom-up and top-down processes. The first two stages are very much top-down-driven by school leadership. However, initiatives are most successful when teachers and students are engaged as active participants in decision making. The third and fourth stages are more ‘bottom-up’ processes: Action is required from the key target groups. The point is that both bottom-up and top-down processes are necessary for success in the whole-school approach.
Although the four stages of change are presented as sequential phases, they are often parallel or cyclic in practice. The school leadership must continue setting priorities and advocating the initiative’s values if teachers are to sustain their commitment. Further, formalization needs to be given high focus as new strategies are developed and need to be integrated in the school organization. Finally, teacher and student behavior need continuous stimulation and facilitation in order to sustain changes over time. A case example presenting how one school worked its way through the four phases is provided in the following discussion.
Case Example
The case is set in a secondary school situated in a suburb of a major city in Norway. The school has three classes at each grade level. Forty percent of the students are immigrants. In this example, concrete actions were undertaken by the school according to four phases of development and implementation described in this research paper.
In the first phase, leadership motivation, the school’s leadership identified a ‘whole-school health promotion initiative’ as a way to achieve change. They anticipated that this approach would allow them to build on their established competencies, to collaborate with partners, and to use policy plans to achieve changes in practice. Further, a whole-school approach to health promotion also fits well with the school’s vision for its work:
This school is to be an active school where everyone is responsible for developing a good environment for learning and contributing to a high level of competence, and should also be a place where the students experience safety, satisfaction, and belonging.
The vision thus emphasizes both learning and the development of a supportive environment. Here exists a balance between these two priorities. On this foundation, school leaders decided to move the project forward by inviting the teaching staff to consider it and to brainstorm about how it might be implemented.
In the second phase, emphasis was given to anchoring health promotion aims and activities within the school’s policy plan. Health promotion was included as one of three strands of development in the school’s policy plan and ‘regular practice.’ The two other strands of development were ‘cultural elements’ and ‘academic improvement.’ The regular practice of the school includes social staff events, special activities for graduates, increased student involvement through the student council structure, and training in the use of information technology for the first-year students.
In identifying aims and relevant activities, the school used Green and Kreuter’s (1999) Precede-Proceed model. In line with the model, they asked themselves the following questions: (1) What are our current challenges? (2) What do we want to achieve? (3) Which actions do we need to take? and (4) How can we implement our actions?
In order to answer question (1), the school asked its university partner to conduct a survey to explore student and staff satisfaction with school as well as their health and health behaviors.
In response to question (2), the leadership invited students and the staff to prioritize areas identified in the survey. In this way, four areas or projects were named: (1) to improve the physical and psychosocial school environment, (2) to establish a cafeteria, (3) to reduce smoking, and (4) to increase physical activity levels.
In response to question (3), the school wanted to build on research that identified how physical surroundings influence behavior and well-being. Therefore, improvements in the school’s physical environment meant painting walls and decorating with art and flowers inside and outside. The aim was to improve the aesthetics and thereby enhance well-being and decrease vandalism. The school succeeded in its approach.
The establishment of a cafeteria served two purposes.
First, the aim was to provide options for students who did not pack their lunch (which is the common approach among Norwegian schoolchildren). The cafeteria made it possible for students to buy and eat healthier foods. Secondly, the cafeteria aimed to create a safe and pleasant meeting place for the students.
The aim of smoking cessation was addressed by introduction of a prepackaged program of proven efficacy.
Finally, to address the challenge of students’ physical activity, the school provided time and opportunities for student recess and after-school activities. Toward these ends, the