KAP comprehensive school health in China ART.pdf

Changes in attitudes, knowledge and behaviorassociated with implementing a comprehensive school

health program in a province of China

Carmen Aldinger1*, Xin-Wei Zhang2, Li-Qun Liu2, Xue-Dong Pan3, Sen-Hai Yu4,Jack Jones5 and Jared Kass6

Abstract

After successful pilot projects, Zhejiang Prov-ince, China, decided to systematically scale-uphealth promoting schools (HPS) over the entireprovince of 47 million. This study describes theinterventions and self-reported changes in atti-tudes, knowledge and behavior during the firstphase of scaling-up. Group interviews wereconducted with a sample of 191 participants(school administrators, teachers, students andparents) from nine schools with a total of;15 200 students. Grounded theory guideddata analysis. Schools implemented all HPScomponents (school health policy, physicalschool environment, psychosocial school envi-ronment, health education, health services, nu-trition services, counseling/mental health,physical exercise, health promotion for staffand outreach to families and communities),adapted to local circumstances. Participantsreported a range of changes in attitudes (payingmore attention to health, attaining better ‘psy-

chological quality’ and confidence, formingfriendships between teachers and students andfeeling more relaxed), knowledge and concepts(increasing knowledge about various healthissues, developing a broader concept of healthand gaining better understanding about theHPS concept) and behavior (actively participat-ing, increasing physical activity, improving san-itary habits, reducing or quitting smoking,eating more nutritiously, increasing safety be-havior, sustaining less injuries and improvingparent–child communication). This qualitativestudy shows the feasibility and efficacy of imple-menting HPS in Zhejiang Province, China.

Introduction

Health promoting schools in ZhejiangProvince, China

In response to the Global School Health Initiative of

the World Health Organization (WHO), regional

guidelines developed by the WHO Western Pacific

Regional Office (WPRO) and with endorsement of

the national Ministries of Health and Education,

some of China’s health and education agencies began

implementing the health promoting school (HPS)

concept in selected schools. In 1996, an HPS pilot

project was established that successfully reduced

parasitic helminth infections in rural schools [1].

This was followed in 1998 and 2000 by two HPS

projects in Zhejiang Province that successfully

addressed tobacco use prevention and nutrition, re-

spectively [2, 3]. A third project in Zhejiang Prov-

ince used materials from United Nations Children’s

Fund to address school-based injury prevention.

1Health and Human Development Programs, Education

Development Center, Newton, MA 02458, USA, 2Health

Education Institute of Zhejiang Province, Hangzhou 310000,

People’s Republic of China, 3Department of Education of

Zhejiang Province, Hangzhou 310000, People’s Republic of

China, 4Institute of Parasitic Diseases Chinese Center for

Disease Control and Prevention, Shanghai 200025, People’s

Republic of China, 5Formerly of Department of Chronic

Diseases and Health Promotion, World Health

Organization, 1211 Geneva 27, Switzerland and 6Graduate

School of Arts and Social Sciences, Lesley University,

Cambridge, MA 02138, USA

*Correspondence to: C. Aldinger.

E-mail: [email protected]

� The Author 2008. Published by Oxford University Press. All rights reserved.For permissions, please email: [email protected]

doi:10.1093/her/cyn022

HEALTH EDUCATION RESEARCH Vol.23 no.6 2008

Pages 1049–1067

Advance Access publication 13 May 2008

by guest on August 17, 2012

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Based on the positive experiences of the pilot

projects, officials of Zhejiang Province decided to

systematically scale-up the HPS project over the

entire province, partially in an effort to achieve

the government-mandated ‘quality education’ that

focuses not only on academic achievement but also

on the child’s physical, social and emotional devel-

opment as well. With joint endorsement of the Pro-

vincial Departments of Education and Health and

support from the WHO, Zhejiang Province’s Health

Education Institute launched an effort in 2003 to

expand the development of HPS to all 11 prefec-

tures of the province. The program started with

a training workshop in Hangzhou in October

2003, for headmasters and teacher representatives

of 51 schools and health and education officers of

the prefectures, conducted by national and interna-

tional health promotion experts.

Insufficient evidence, especially fromdeveloping countries

Despite the successful pilot projects and a signifi-

cant body of theory and research that provides

a rationale for why health education, as part of

a comprehensive school health program, can be

useful and beneficial to health (e.g. [4–6]),

researchers still report insufficient evidence of the

feasibility and effectiveness of HPS. Some articles

reported that there is no universally accepted and

clear definition of what constitutes an HPS [7] and

no consensus on the criteria by which those schools

can be assessed [8, 9]. Also, studies by some of the

same authors concluded that there is currently in-

sufficient evidence in the literature to support the

efficacy and feasibility of implementing an HPS

approach [10, 11].

In addition, there is a lack of research from de-

veloping countries and particularly a scarcity of re-

search on scaling-up. An article from the WHO

Bulletin notes five factors that might underlie a lack

of evaluation research from developing countries:

poor research production, poor preparation of

manuscripts, poor access to scientific literature,

poor participation in publication-related decision-

making processes and bias of journals [12].

There are few evaluations of the full scope of

HPS interventions, as it is challenging to evaluate

the complexity of HPS. One study looked at the

incorporation of principles of the Ottawa Charter

for Health Promotion—healthy school policy, sup-

portive school environment, school community ac-

tion, developing personal skills and reorienting

services—in school-based programs published be-

tween 1983 and 1995 that targeted smoking and/or

alcohol and/or solar protection. The study found

that none of the programs incorporated all five com-

ponents of the HPS approach. Only four programs

(4.5%) utilized four of the five components and two

programs (2.3%) addressed three components [13].

A 2006 systematic review of school health promo-

tion and the HPS approach also found that none of

the schools in 12 controlled before and after studies

(mostly conducted in the United States) imple-

mented all the components of the HPS approach.

This study endorsed the HPS approach and con-

firmed the challenge of implementing and evaluat-

ing a comprehensive approach [14].

Research questions and purpose

In an effort to fill some of these gaps in research, to

investigate how the complex framework of HPS is

being implemented in a developing country and

how it affects participants, this study seeks to an-

swer the following questions: What interventions

have schools in Zhejiang Province implemented

to become HPS? What self-reported changes took

place in the lives of individuals during the imple-

mentation process?

Materials and methods

Theory

This study falls into what Smith called institutional

ethnography, a process in which interviewing is

part of an approach to investigate organizational

and institutional processes rather than informants’

inner experiences [15]. An institution, in this case,

does not refer to a particular type of organization,

but to coordinated and intersecting work processes,

such as health care or, in this case, HPS. The

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purpose of this research is to discover and describe

processes of ‘how it happens’ based on putting to-

gether an integrated view from the otherwise trun-

cated accounts of each informant [15].

Context

This study provided a unique opportunity to add

a qualitative evaluation component to an ongoing

HPS project. The WHO asked Zhejiang Province,

as part of the HPS project, to conduct a series of

surveys to gather quantitative data: the Global

School-based Student Health Survey (GSHS) for

13- to 15-year olds, which assessed risk and pro-

tective behaviors related to health; evaluation index

for HPS Bronze Awards (from WHO/WPRO),

which assessed in detail the various aspects of

HPS components that the schools implemented;

WHO Psychosocial Environment Profile, which

assessed perceptions of the social and emotional

school environment and a content-related question-

naire from former pilot projects in China, which

assessed knowledge, attitudes and behaviors. The

first three instruments were generated through

WHO, the latter was developed by Chinese experts.

As a complement to these quantitative measures,

authors of this study developed qualitative meas-

ures to assess the process and procedures of imple-

menting HPS and participants’ experience with the

project.

Participants

This study was part of a WHO project in China with

specific goals and cultural considerations. Partici-

pation was controlled by the Chinese colleagues.

The Health Education Institute of Zhejiang Prov-

ince chose the participating schools based on guid-

ance from the research team: For the first round of

data collection, one former pilot school and two

schools that joined the project in the first scaling-

up phase—one from a resource-poor area and one

from a resource-rich area—were included. The fol-

lowing two rounds of data collection included only

schools from the scaling-up phase. At least one

school from a resource-poor area was investigated

in each round. The rationale for this choice was to

examine if and how HPS could be implemented in

both resource-rich and resource-poor environments.

Schools chose the interviewees based on the guid-

ance in the protocol: one to two school administra-

tors (e.g. principal and vice principal), four to six

teachers (from different subject areas) and/or other

implementers (such as school doctor), four to six

students (from different grade levels) and four to six

parents (from different socioeconomic back-

grounds), representing a mixture of males and

females for each group.

Nine schools with a total population of ;15 200

students participated in the study. The sample of

191 interview participants for this qualitative study

included 26 school administrators (19 males and

7 females), 56 teachers and school staff (21 males

and 35 females), 64 students (25 males, 34 females

and 5 gender not recorded by research team) and

45 parents (14 males and 31 females). Gender bal-

ance was not always possible for practical reasons

such as more males than females being in the

school’s administrative positions. This sample rep-

resented two elementary schools, two middle

schools, two junior high schools, one high school

and two vocational schools. Demographics of par-

ticipants are presented in Fig. 1.

Instruments

Protocols contained questions for interviews with

school administrators, teachers and other imple-

menters, students and parents. The Institutional Re-

view Board (IRB) of the employer of one of the

authors reviewed the initial protocol and deter-

mined on 19 April 2004 that the protocol met the

criteria for exemption from expedited or full IRB

review. Subsequently, the Human Subjects Com-

mittee at the authors’ academic institution waived

on 7 May 2004 the need for the IRB to review the

research.

For each round of data gathering, a questionnaire

with structured, open-ended questions, developed

by the research team, had a different focus. The first

round of data gathering focused on planning, the

second round focused on implementation and the

third round focused on monitoring and evaluation.

In the second and third round, participants were

Comprehensive school health program in a province of China

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School 1 School 2 School 3 School 4 School 5 School 6 School 7 School 8 School 9

Date

Interviewed

June 4,

2004

June 7,

2004

June 8–9,

2004

Nov 22,

2004

Nov 24,

2004

Nov 25,

2004

Nov 14–

15, 2005

Nov 16,

2005

Nov 18–19,

2005

Type of school Elementary Middle

School

High

School

Middle

School

Experime

ntal Junior

High

Vocational

school

Vocational

school

Elementary Junior High

School

Location Urban Suburban/

Rural

Suburban Urban Urban Suburban Rural/

Suburban

Rural Urban

Entry point Nutrition Nutrition Psycholog

ical health

Tobacco

control

Psycholog

ical health

Nutrition Injury

prevention

Injury

prevention

Psychologic

al health

Number of

students

n ~ 15,207

1,300 1,100 1,800 1,600 950 2,200 2,500 1,157 2,600

Number of

teachers and

staff

66 (not

recorded)

(not

recorded)

100 80 162 staff 100 51 full-

time

120–130

Interviewees:

Administrators

n = 26

7 females

19 males

n = 1

1 female:

Principal

n = 2

2 males:

Principal,

Vice

Principal

n = 2

2 males:

Principal,

Vice

Principal

n = 3

3 males:

Principal,

Vice

Principal,

Director

of Admin

n = 2

1 female:

Principal

1 male:

Vice

Principal

n = 3

3 males:

Principal,

Vice

Principal

(2)

n = 4

2 females:

Vice

Principal,

Office

n = 6

1 female:

Director

n = 3

2 females:

Vice

Principal,

Administrat

orDirector

2 males:

Vice

Principal,

Chairman

of Board

Teaching

5 males:

Principal,

Vice

Principal,

Consultg

Teacher,

Accountan

t, Director

of Teachg

1 male:

Principal

of

Fig. 1. Demographics of study participants.

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School 1 School 2 School 3 School 4 School 5 School 6 School 7 School 8 School 9

Nurse;

Math

2 males:

Phys ed;

Researcher

3 males:

“Students’

work,”

Biology,

English

Nurse,

Chemistry

1 male:

Phys ed

3 males:

Phys Ed

(2), Math

Sociology

1 male:

Math

3 males:

Phys Ed,

Cooking,

Sociology

ce

3 males:

Public

Relations,

Secretarie

s, Infor-

mation &

Career

Dev

Chinese

(2), Phys

Ed, Math

Sociology,

School

Nurse

1 male:

Chinese

Students

n = 64

34 females

25 males

5 not recorded

n = 7

3 females,

4 males

n = 5

(not

recorded)

n = 6

3 females,

3 males

n = 7

5 females,

2 males

n = 7

4 females,

3 males

n = 7

5 females,

2 males

n = 6

4 females,

2 males

n = 14

7 females,

7 males

n = 5

3 females,

2 males:

Teachers

n = 56

35 females

21 males

n = 7

5 females:

Morality;

English;

Chinese;

School

n = 6

3 females:

Math,

Physics,

Phys ed

n = 5

4 females:

Psycholog

ist,

Chinese,

School

n = 6

3 females:

Sociology,

English,

School

Nurse

n = 7

6 females:

Math,

Sociology,

Chinese

(3),

n = 6

3 females:

Music,

Chinese,

School

Nurse

n = 6

3 females:

Math,

Computer,

Document

Maintenan

n = 6

2 females:

Chinese

(2)

4 males:

n = 7

6 females:

English,

Phys Ed.,

Math,

Science,

Parents

n = 45

31 females

14 males

n = 6

6 females

n = 1

1 female

n = 2

2 females

n = 5

(including

1 grand-

parent)

2 females,

3 males

n = 7

4 females,

3 males

n = 6

3 females,

3 males

n = 4

2 females,

2 males

n = 8

7 females,

1 male

n = 6

4 females,

2 males

* Key schools are schools distinguished from ordinary schools by their academic reputation and are generally allocated moreresources by the state. Their original purpose was to quicken the training of highly needed talent for China’s modernization,but another purpose was to set up exemplary schools to improve teaching in all schools (p. 244). [24]

Fig. 1. Continued


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asked to provide written answers during the first

part of the interview which were then collected at

the end of the interview. A summary of interview

questions is included in Fig. 2. The questionnaire

was translated from English into Chinese prior to

the interviews by an interpreter who was part of the

initial HPS training in Zhejiang Province.

Procedure

Data collection took place during three separate vis-

its to Zhejiang Province in June 2004, November

2004 and November 2005. Each round of data

collection included four group interviews in each

of three schools. Each group interview with one

of the target groups (school administrators, teach-

ers, students, parents, respectively) lasted ;1 hour.

The interpreter asked the questions in Chinese

and translated the responses into English. One

member of the research team was Chinese. He

assisted with translations or clarifications, as

needed. A different interpreter assisted on each of

these three rounds of data collection, arranged by

the Health Education Institute. Two other inter-

preters, hired by the research team, translated writ-

ten responses. In addition, the research team

reviewed files with documents and pictures at the

schools and toured all but one school (one school

was not toured for lack of time) to make observa-

tions in an effort to triangulate the data from the

interviews.

Prior to the interviews, the interpreter received

some background on the project, HPS documents

and the protocol and instructions for the interviews.

At the beginning of each interview, and as part of

the protocol, the interpreter mentioned that the

interviews were to gather the participants’ experi-

ences and opinions in order to strengthen the imple-

mentation of the HPS project. The interpreter

stressed that each participant’s opinion was impor-

tant, that there were no right or wrong answers, that

participants should feel comfortable expressing

their ideas about the topics discussed and that their

answers would be reported anonymously to ensure

confidentiality. Interviewees agreed to have the

interviews tape-recorded.

Data analysis

Data analysis consisted of preparing the

data—including transcriptions and translations—

and analyzing the data with the qualitative data

management program Atlas.ti in two stages. The

first stage of data analysis was guided by grounded

theory which provided an opportunity to generate

theory that is grounded in data [17]. The second

stage of data analysis was guided by theoretical

frameworks such as the HPS framework [18]. This

article focuses on the first stage of data analysis

which utilized open coding.

Results

The study provided detailed results about interven-

tions for implementing all the components of an

HPS and about self-reported changes in attitudes,

knowledge or concept and behaviors of partici-

pants. This article provides a summary.

Implementing the components of an HPS

Schools in Zhejiang Province implemented com-

prehensive interventions that addressed all of the

components of HPS as follows.

For ‘school health policy’: Schools made HPS

regulations for each school department, established

non-smoking policies and posted policies on school

walls or boards. To create a healthy ‘physical

school environment’: Schools improved facilities

such as dining rooms, dormitories, teaching and

sports facilities, enhanced cleanliness and held

beautification projects. To improve the ‘psychoso-

cial school environment’: Schools assured a harmo-

nious and caring psychosocial atmosphere,

established good relationships between teachers

and students and provided equal treatment. To im-

plement ‘health education’: Teachers integrated

health topics into regular teaching and increased

use of participatory teaching and learning methods,

held special health education classes, extracurricu-

lar activities and drawing and writing competitions.

For ‘health services’: Schools offered annual med-

ical checkups for students and staff, prevention and

treatment of common diseases and—those with

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dormitories—had doctors on 24-hour duty. To im-

plement ‘nutrition services’: Schools offered nutri-

tious and balanced meals, more food variety and

training by nutritionists for kitchen staff. For ‘coun-

seling/mental health’: Schools offered psychological

consultation by specially trained teachers, hotlines,

First round: focus on planning (June 2004)

For school administrators:

What is your position at this school?

What health topic has your school selected as an entry point? How was that topic

selected?

Does your school have an HPS planning committee? Who is part of the planning

committee? How were these people chosen? What are their roles?

Does your school have a work plan developed (or will it develop a work plan)? Who was

(or will be) involved in developing this work plan? How did (or will) you decide what to

include?

For teachers:

What grades and subject do you teach?

How do you choose what topics to address and which methods to use? Why?

For students:

In which grade are you?

Do you know if any students are part of the working committee that plans the new health

activities? If so, what is their role?

For parents:

In which grade is your child?

Do you know if parents are involved in an HPS planning committee that plans the new

activities? How did they get involved?

For all:

Can you describe to me what you think a Health-Promoting School is?

How did you learn about the HPS concept? From whom?

How do you feel about your school becoming a Health-Promoting School? Why?

Which new activities have you done at school since April/May when the health

interventions started?

What challenges do you expect? How could they be handled?

Fig. 2. Interview questions.


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special mailboxes and set up special consultation

rooms. To improve ‘physical exercise’: Schools re-

quired morning exercises and engaged in sports

matches. To encourage ‘health promotion for staff’:

Schools encouraged staff to quit smoking—for in-

stance, through smoke-free school regulations—

and to exercise more and offered psychological

consulting for teachers. For ‘outreach to families

make this school a Health-Promoting School?

What teaching and learning materials and methods have you used in your classroom? Have

you tried any new teaching and learning methods since last November? If so, what new

methods did you try and how well did they work?

For students:


What has been done differently in your school since last November to help make your school

a Health-Promoting School?

What (if anything) have you personally done differently since your school became a Health-

Promoting School?

In what ways, if any, are students helping their school to become a Health-Promoting

School? To what extent do you think students can help make a difference?

Second round: focus on implementation (November 2004)



What health topic (or topics) has your school selected as an entry point? How was that topic

selected?

Does your school have an HPS planning committee? Who is part of the planning committee?

How were these people chosen? What are their roles?

Does your school have a work plan to become a Health-Promoting School?

Which interventions have been implemented since last November?

How were these interventions chosen? Why were they chosen?

For teachers:


Do teachers choose the health topics that they address with their students? (If relevant), what

are some of the topics that you have chosen? Why did you choose these particular topics?

What interventions have been implemented since last November in support of your effort to

Fig. 2. Continued.

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What challenges were encountered? How can these challenges be addressed?

What else can you tell me about what you have learned that would be helpful to others who

want to implement effective school health programs?

Do you have any further comments or questions?

Third round: focus on monitoring and evaluation (November 2005)



Please tell me if you did anything to assess the implementation or effectiveness of the

interventions. If so, please tell me what you did and what you found. Tell me if you made

any changes based on your findings, and if so, what kind of changes you made.

For teachers:


Please tell me if you did anything to assess the implementation or effectiveness of the

interventions. If so, please tell me what you did and what you found. Tell me if you made

any changes based on your findings, and if so, what kind of changes you made.

For students:


For parents:


For parents:


What has been done since last November to help make your child’s school a Health-

Promoting School?

What (if anything) has been different for you personally since your school began working to

become a Health-Promoting School?

In what ways, if any, are parents helping their school to become a Health-Promoting School?

To what extent do you think parents can help make a difference?

For all:

Can you describe briefly what you think a Health-Promoting School is?

So far, what went well in your school’s effort to become a Health-Promoting School?

Fig. 2. Continued.


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and communities’: Schools distributed materials to

communities, sent letters, made calls to parents and

conducted parents’ school (teaching parents in the

evening or on the weekend about health).

Besides addressing all HPS components, schools

in Zhejiang Province also engaged various people

such as parents and community members in devel-

oping HPS, as suggested by the HPS framework.

A summary of interventions for each component

is included in Fig. 3.

Changes in attitudes

‘Attitude changes’ for many participants included

‘paying more attention to health’. For example,

people realized the importance of nutrition and of

healthy surroundings, the danger of smoking, the

importance of hygiene and safety and developed

health consciousness, including attention to psy-

chological health. Students (and staff) ‘attained

better psychological quality and confidence’. This

included the ability to handle difficulties, more

confidence, becoming more communicative and

improving emotional and self-control. This contrib-

uted to richer lives, increased motivation to study

and more enjoyment. School administrators ‘put

themselves in others’ shoes’ first to better under-

stand others’ behavior. Some schools experienced

‘friendships between teachers and students’. Stu-

dents turned to teachers for help if they had prob-

lems and treated teachers ‘like friends’. Teachers

felt valued, like a ‘big brother’, and experienced

more satisfaction with their work. This was cited

as unusual in China, where teachers are tradition-

ally responsible for teaching and disciplining stu-

dents, and schools and the society expect students

to focus on their studies. These developments made

parents ‘more relaxed’ because they gained confi-

dence that the school was taking good care of their

Please tell me your overall impression/assessment of the HPS project at your school.

(Why do you think this way?)

Please tell me: What was the (one) most important positive outcome/change since your

school has become a Health-Promoting School? How was it before your school became a

Health-Promoting School? How was it afterwards?

Please tell me what has been different in your life since your school became a Health-

Promoting School

Do you have any further comments or questions?

If time allows:

Please tell me what challenges were encountered with implementing and evaluating HPS

interventions. How can these challenges be addressed?

What else can you tell me about what you have learned that would be helpful to others

who want to implement and evaluate effective school health programs?

For all:

Hold up the Chinese characters for “Health-Promoting School.” Can you please describe

what this (the HPS concept) means to you?

Fig. 2. Continued.

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Components of Health-Promoting Schools

School health policy

e.g., smoking ban

regulations for each school department and many health-related items

including safety regulations

posted policy on school walls or boards

handbook for student behavior

Physical school environment

e.g., improved facilities, including dining room, dormitories, sports facilities

multimedia classroom

improved sanitation facilities and reduced littering

green, clean and beautiful school environment

meeting WHO and national standards

Psycho-social school environment

e.g., teachers and students became friends

harmonious relationships

equal treatment

student support groups

Health education

e.g., integrating health into regular teaching

special health education classes

drawing and writing competitions

professionals gave lectures, workshops

Health services

e.g., annual medical check-ups for students and staff

prevention and treatment for common diseases

doctors on duty

Nutrition services

e.g., nutritious meals, more food variety

balanced fixed plates

training and advice from nutritionists for kitchen staff

Fig. 3. Examples of implemented HPS components.


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children, that the school provided safe and harmo-

nious surroundings (e.g. with good relationships

between teachers and students and among students)

and that their child was improving his or her self-

control and psychological quality.

Changes in knowledge and concepts

‘Health-related knowledge gains’ included in-

creased knowledge about nutrition, hygiene, safety

and security, the harm of tobacco, how to avoid

injuries and psychological knowledge such as

how to relieve anxiety and what is normal and ab-

normal. (This will be further detailed elsewhere in

reports about the quantitative evaluation of the

interventions.) A knowledge transfer occurred from

children to parents. Participants also developed

a ‘broader concept of health’ that included not only

physical health but also psychological and social

health. An ‘understanding of the HPS concept’ de-

veloped over time. It included gaining of knowl-

edge and understanding of different components

of the concept for different participants. Actively

involved school administrators developed the most

complex understanding of the HPS concept, fol-

lowed by teachers, students and parents who devel-

oped a less complex but sufficient understanding to

recognize it as providing a positive quality to the

school.

Changes in behavior

‘Behavior changes’ included more ‘active partici-

pation’ in the project. Students and parents actively

participated in activities such as publicizing health

knowledge to neighbors and friends and taking part

Counseling/ mental health

e.g., psychological consultation by specially trained teachers

hotline, special mailbox, special consultation room

consultation for teachers

Physical exercise

e.g., morning exercises

sport matches such as football, basketball, volleyball

improved sports facilities

Health promotion for staff

e.g., encouraged staff to quit smoking

more exercise and walking

psychological consulting for teachers

Outreach to families and communities

e.g., distribution of materials, letters to parents

visits and calls to parents’ homes

parents’ school

increased parent-child communication

students distribute health information (“publicity”) in the community

Fig. 3. Continued.

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in school events. Some participants ‘increased their

physical activity’ and did more physical exercise

such as utilizing the school playground or walking

to school rather than taking the bus. Students also

‘improved sanitary habits’ such as not throwing

litter on the ground, paying attention to personal

hygiene such as brushing teeth twice a day, washing

hands before and after dinner and after using the

toilet, cutting their nails regularly and washing their

clothes. Many teachers and parents ‘reduced or quit

smoking’. Some children persuaded their fathers

and grandfathers successfully to reduce or quit

smoking. Administrators and staff quit smoking

or did not smoke on school grounds, especially if

the school established no-smoking rules. Partici-

pants also ‘changed bad habits’ and developed

good habits. This included a variety of habits, such

as paying attention to personal health issues, dis-

playing civilized behaviors, improving living hab-

its, self-adjustment and adaptability. Students

persuaded their classmates and friends to change

their habits. Participants also ‘ate more nutritiously’

such as not eating fried food, intentionally buying

healthy food and balancing their diets rather than

having special food preferences. Vendors who sold

unqualified foods outside one school moved away

because students and teachers stopped buying from

them. ‘Increased safety behaviors’ included stu-

dents wearing yellow safety hats and walking to-

gether, not taking vehicles without certificates,

wearing safety helmets and obeying traffic rules

when riding a bike. Consequently, accidental ‘inju-

ries decreased’ significantly. For instance, in one

school, accidental injuries dropped ;41% within

1 year and a half, and in another school, injuries

decreased almost 39% from one school year to the

next, according to statistics kept by the school. ‘Par-

ent–child communication’ improved. As the only

child, children in China were at the center of their

family, and children could teach their parents and

grandparents about healthy behaviors. In turn,

parents had more communication with their child

and shared their own growing up experiences. Chil-

dren with lower academic scores got more commu-

nicative with parents after they had opportunities to

express their talents at school in different ways.

HPS helped parents and students to communicate

with each other, and children became more sociable

and shared new experiences that happened in

school with their parents.

A summary of these self-reported changes in par-

ticipants is included in Fig. 4.

Discussion

Unique aspects of this study included that schools

implemented truly comprehensive interventions, par-

ticipants expressed their understanding of the broad

concept of health and HPS and program implement-

ers recognized children’s status within the families in

China as a particularly unique and promising oppor-

tunity to influence the health of parents and grand-

parents. In addition, this study pointed to the need for

training and demonstrated the value of a qualitative

approach to school health research.

Implementing truly comprehensiveinterventions

This study showed that schools implemented com-

prehensive interventions in three aspects: first,

schools addressed all the components of an HPS;

second, schools addressed various health topics and

third, schools focused on holistic development of

students.

Schools used their full organizational potential

by implementing all HPS components. Thus, unlike

the studies by Lynagh et al. [13] and Stewart-

Brown [14] that showed that none of the programs

incorporated all five components of the Ottawa

Charter in the HPS approach, this study showed

that the visited schools in Zhejiang Province

addressed virtually all of the components of the

Ottawa Charter at school level (policy, supportive

environment, community action, personal skills and

health services). The variety of activities that

schools reported was a good example of the under-

standing and application of a comprehensive ap-

proach to health, as called for by the HPS

concept. As noted by a deputy headmaster, their

understanding of health became more comprehen-

sive and, consequently, their ideas and interven-

tions also became more comprehensive.


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Attitude changes

Paying more attention to health

Realizing the importance of health and paying more attention to health

Attaining better “psychological quality” and confidence

Students, and some staff, improving their psychological qualities, including their

ability to handle difficulties, and increasing their confidence

Forming friendships between teachers and students

Teachers becoming like friends of students

Feeling more relaxed

Parents, some students and administrators, feeling more relaxed

Knowledge and conceptual changes

Increasing knowledge about health issues

Participants increasing their knowledge about health, nutrition, hygiene, safety and

security, the harm of tobacco, how to avoid injuries, and psychological knowledge

Developing a broader concept of health

Participants realizing that health is a broader concept that includes physical, mental and

social health

Gaining a better understanding about the HPS concept

Participants expressing a very comprehensive understanding of the components and

concept of a Health-Promoting School

Behavior changes

Actively participating in the project

Students and parents actively participating in the project, spreading knowledge and

forming good habits

Increasing physical activity

Some participants increasing their physical activity

Improving sanitary habits

Students decreasing littering and improving their hygiene habits, such as hand washing and

brushing teeth

Fig. 4. Participants’ self-reported changes.

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Furthermore, schools implemented a truly compre-

hensive approach that addressed various health top-

ics. In contrast, school health programs in developed

countries often focus on one health issue. For in-

stance, in the United States, there is an extensive data-

base of programs that focus only on substance abuse

prevention and treatment programs that have pro-

duced favorable results (http://modelprograms.samhsa.

gov/). Schools in Zhejiang Province addressed not

only the health issue that they had chosen as entry

point, but all the schools in this study addressedvarious

health issues. Inmost cases, this included tobacco con-

trol, nutrition, exercise, psychological health, hygiene,

as well as other prevalent health issues such as inju-

ries or severe acute respiratory syndrome (SARS).

In addition, schools started to focus on holistic

or ‘all-around development’ of students, not just

academics. This was supportive of the approach

to quality education called for by the Chinese gov-

ernment. For example, in one school, a teacher

thought that the greatest achievement of this project

was that after implementing the project for

1.5 years, he focused on academic learning but

cared for the students in all aspects.

Thus, implementing HPS was a comprehensive

approach in many aspects: implementing a wide

range of interventions, addressing various health

topics and addressing holistic development of

students.

Understanding the broad concept of HPS

The apparently increased level of understanding of

a broad concept of health and of the HPS con-

cept—that is based on an understanding of a broad

Reducing or quitting smoking

Many teachers, fathers and grandfathers reducing or quitting smoking

Changing various bad habits

Many participants changing their bad habits such as sanitary and other living habits,

and persuading others to change their bad habits, too

Eating more nutritiously

Students and their families changing to a more balanced diet, less fried food, more

vegetables, etc.

Increasing safety behavior

Students wearing yellow safety caps and walking together, not taking bicycles or

vehicles without certificates to school

Parents and teachers wearing safety helmets

Sustaining less injuries

Injuries in two schools dropping by about 40 percent

(according to statistics on injuries kept by the schools)

Improving parent-child communication

Children having better communication with their parents

Parents communicating more with their child

Fig. 4. Continued


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concept of health—might be one of the project’s

most important achievements. As has been docu-

mented in nursing, ‘an understanding of the client’s

concept of health is necessary to conduct relevant

and effective health assessment, planning, interven-

tion and evaluation’ [19]. This is also crucial in

health promotion.

Since data in Zhejiang Province could not be

gathered in the same schools during subsequent

visits, these data cannot prove with certainty that

the level of understanding has improved in any par-

ticular school. However, the findings clearly indi-

cate that, during the first round of data collection,

participants’ level of understanding of the health

concept was less well developed. For example, dur-

ing the first round of data collection, some parents

and children were reluctant to answer when asked

to describe an HPS. There was also a challenge of

translating the concept into Chinese. One teacher

asked during a training session if the characters

meant ‘Health Promotion School’ or ‘health pro-

motes school’. During the second round of data

collection, participants’ responses demonstrated

a much deeper and more detailed understanding

of the nature and scope of HPS than the earlier

interviews. For example, a school administrator de-

fined six features of HPS and thus demonstrated

a good understanding of the components of HPSs

as well as an understanding of health in a broad

sense. Participants’ responses during the third

round of data collection revealed a similarly de-

tailed concept of health and HPS. Respondents

reported repeatedly that their concept of health

changed during the implementation of this project

from a narrow focus on physical health to a broader

focus that included social and psychological health.

This implies that the level of understanding of

a broad concept of health grew profoundly in pro-

ject schools during the implementation period.

Engaging children in educating parents andserving as change agents

Children passed on health information to their

parents and grandparents, many of whom had

a lower level of education. Thus, children were

often effective teachers of their parents and initia-

tors of attitude and behavior changes.

For example, one school asked their students—

when they went home during their summer or win-

ter vacation—to explain the contents of the

students’ handbook, with basic knowledge about

health, to their parents. In another school, one

mother expressed that the students could serve as

a bridge to spread knowledge, and when children

said something, the adults would pay more atten-

tion to it. This was considered better than adults

spreading the knowledge to each other. Children

had a special role since they were usually an only

child—due to China’s one-child policy—so parents

and grandparents paid special attention to this ‘little

emperor’. The recognition of this unique status of

children in China and its potential to affect change

are unique to this study.

However, the role of children to educate their

families is not only a Chinese phenomenon. In

India, children have also been health promoters. A

2005 article reports ‘The school children, who are

the first generation to be educated, became the

agents of change. Their role was to promote healthy

behaviors amongst younger children, children of

same age, their immediate families and larger com-

munity’ [20, p. 148].

Thus, HPS projects can seize on unique circum-

stances of cultures and communities to enable chil-

dren to be effective change agents, especially in

developing countries and among a parents’ genera-

tion with low levels of education.

The need for training

One of the most frequently mentioned challenges

was a perceived lack of professional development

and support to expand knowledge, skills and expe-

rience about health promotion.

For instance, in some schools, teachers asked the

research team to pass on ‘advanced knowledge’.

In one school, teachers first thought that their nu-

trition knowledge was sufficient, but when the pro-

ject gained in intensity, they felt a need for more

professional instruction and hoped for more ex-

pert talks, though they also acknowledged that

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‘knowledge is not enough’ and that some students

knew better than teachers. The research team also

observed that, while the schools conducted all the

required surveys, they did not seem to know how to

interpret the data to use for program planning.

Training has been shown to be crucial for health

education. For instance, evaluation of a comprehen-

sive health education curriculum in the United

States showed that trained teachers were better pre-

pared, implemented the curriculum with more fidel-

ity and achieved more positive effects on student’s

knowledge [21].

Thus, this study confirmed the importance of

teacher training and pointed to the need for more

professional development in health promotion con-

cepts, knowledge, skills and experiences about HPS

and related issues.

Qualitative approach to research

In addition to demonstrating positive behavioral

and attitudinal outcomes from this HPS project, this

study also demonstrated the value of a qualitative

approach to HPS research.

Through in-depth interviews and focused inves-

tigative dialogues with participants, this study gen-

erated a complex picture and understanding of the

multidimensional process of change which occurs

during an HPS project. Precisely, because HPS

projects promote change in the ‘whole person’

and the ‘whole system’ through which a school

operates, they require a multidimensional analysis

which is sensitive to the interplay between the in-

tellectual, social, emotional and systemic aspects of

learning and change. In such ‘holistic’ interven-

tions, qualitative approaches to data collection and

analysis provide important benefits.

The benefits of a qualitative approach do not

negate the value of quantitative assessments of prog-

ress. Rather, they can contribute a rich, more nu-

anced understanding of complex change processes

that quantitative methods cannot capture [22].

Limitations

There were a number of limitations in the method-

ological design of the study that were inherent in

the complexity of this HPS project that could not

be avoided. They were part of the real-world re-

alities in which such projects must operate. The

limitations of this study were related to the role

of the researcher, social desirability bias, language

and interpretation/translation, culture, timing of

interventions and surveys, study design and self-

reporting.

Particularly in qualitative research, it is important

to consider the role that the researcher plays [23]. It

was obvious that the Health Education Institute

paid special attention to the research team whom

they accompanied during the interviews, which

could potentially influence the responses. During

many of the group interviews, additional people

were present besides those being interviewed and

at least some of the participants seemed to be pre-

pared for the interviews and had notes. This was

understandable because of the high importance at-

tached to the visit of ‘foreign experts’. This has also

been observed in other settings [24]. Despite this,

many participants seemed to share very openly,

even about their challenges.

Language and cultural differences and the need

for interpretation/translation across languages can

contribute to misunderstandings and false interpre-

tations [22]. Ideally, a native speaker should con-

duct such research, but short of that, international

researchers can help bring findings from developing

countries into English-speaking literature.

The study revealed that some of the interventions

already existed before schools became HPS. How-

ever, it also showed that the HPS approach fit well

with existing activities and enabled schools to im-

plement a truly comprehensive approach.

The initial plan was to interview the same three

schools that were interviewed during the first round

of data gathering at two more time intervals. This

was culturally not appropriate because the schools

would have received a disproportional amount of

attention and resulting local publicity. Conse-

quently, different schools of the same cohort and

with similar characteristics were selected for the

second and third round of data gathering. Thus,

the study design had to be flexible in order to ac-

commodate the actual situation.


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All of these data are self-reported, just as major

school health surveys such as the Youth Risk Behav-

ior Surveillance of the US Centers for Disease Con-

trol and Prevention and the GSHS of WHO also

depend on self-reporting. As in these major surveys,

it is difficult to verify the data. Talking to various

groups of people at various schools and time inter-

vals, supplemented by observations, allowed for

some triangulation in this study. Triangulation refers

to ‘using multiple methods in order to obtain more

thorough coverage of a subject by viewing it from

different angles’ [25]. This study design was based

on what was feasible in the given situation.

Conclusion and recommendations

This study showed that it was feasible and effective

to implement the HPS project in Zhejiang Province,

China, focusing on different health issues and with

different levels of resources. Based on these posi-

tive findings, and as participants suggested, the

HPS project should be implemented more widely

in China and in other parts of the world.

Funding

World Health Organization to Health Education In-

stitute of Centers for Disease Control in Zhejiang

Province HQ/05/121651, S.-H. Y. HQ/04/893602

and Education Development Center HQ/05/120607

and HQ/05/12011.

Acknowledgements

We want to sincerely thank all the 191 people who

were interviewed for this study.

Conflict of interest statement

None declared.

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Received on October 18, 2007; accepted on March 23, 2008


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