08 SES 12 A, Implementation, Methodology, Integration - Lessons Learnt
Implementing health promotion programmes in school settings(I.U.H.P.E. 2009; SHE network 2013; Safarjan et al. 2013; Simovska et al. 2011)is key to address health inequalities and improve children’s health and well-being. Nonetheless, the core business of schools is focused on educational outcomes, rather than the reduction of health problems. From an educational point of view, schools contribute to health by: i) creating the conditions for pupils’ achievement through improvement of the school environment; and ii) acquiring health competencies to empower young and future generations to make healthy decisions. Promoting health in schools means developing a policy at the school level, which remains difficult.As Don Nutbeam (2013) stated, despite “innovation, energy and enthusiasm, achieving successful implementation and sustaining the positive benefits for school students of school health programmes has proven to be challenging”. Achieving expected results in school settings is laborious and requires to understand discrepancies between expected and actual outcomes. Focusing on the implementation process itself is critical to inform potential further development of practice (Samdal & Rowling 2013).
Such discrepancies are due to the embedded variability in contexts, which quite often differ from what had been foreseen during programme design, which to some extent, was undertaken out-of-context. When considering the variability embedded in contexts, it seems paradoxical to wish for and strive for programme fidelity, which in the end resembles more enforcement than it does co-construction, especially in multi-level and ecological approaches (Pettigrew et al. 2014). Instead, programmes may be considered added ingredients, “something extra” brought to and introduced to local ecology. When this added opportunity, or sometimes constraint, enters the context, interactions occur to result in short to long term outputs and outcomes on different levels of the local ecology (Trickett & Beehler 2013). Programme implementation is thus an enabling (or constraining) process towards a combination of expected achievements: (1) a potential impact on the targeted health issue; and potential outputs, i.e. (2) health capacity building, which materializes through the development of health-related actions and projects, and last butnot least, (3) settings’ and communities’ capacity to promote health, which includes the development of local level policy (St Leger & Young 2009).
Our proposal is to understand and question the implementation process in school settings. The strong idea, and almost advocacy conveyed through this work, is the belief that a strong anchoring in the differences and potentialities of contexts has to also show in research designs. It is crucial to hope to upscale practice and provide support to professionals, starting where people are, and potentiating existing resources.
For the purpose of acquiring a detailed and complex understanding of what is at play during implementation, the focus was set on what kind of outputs are created by the implementation of single programme over time, as well as what factors and combinations of factors can be deduced to influence implementation, from a long-term perspective. The format of this study is retrospective in order to capture potential outputs and processes that are not accessible on a short-term basis. Two types of outputs shall be considered: the development of health-related policy on a school level, and actions implemented by staff after participation to the programme; and potential health capacity building outputs. Three leads were undertaken for this research (1) pinpointing outputs of implementation on a staff and school level from a long-term perspective, and (2) understanding what key factors and combinations of key factors are involved in the effects observed, (3) and also identifying putative recurrences in combinations of contextual factors (Pommier et al. 2010).
Crisp, B.R., Swerissen, H.A.L. & Duckett, S.J., 2000. Four approaches to capacity building in health : consequences for measurement and accountability. Health promotion international, 15(2). Hirsch, G.B., Levine, R. & Miller, R.L., 2007. Using system dynamics modeling to understand the impact of social change initiatives. American Journal of Community Psychology, 39(3–4), pp.239–253. I.U.H.P.E., 2009. Achieving Health Promoting Schools: Guidelines for promoting health in schools. Available at: http://www.iuhpe.org/images/PUBLICATIONS/THEMATIC/HPS/HPSGuidelines_ENG.pdf. Meyers, D.C., Durlak, J.A. & Wandersman, A., 2012. The Quality Implementation Framework: A Synthesis of Critical Steps in the Implementation Process. American Journal of Community Psychology, 50(3–4), pp.462–480. Pawson, R. & Tilley, N., 1997. An introduction to scientific realist evaluation Sage, ed., London. Pettigrew, S. et al., 2014. Process evaluation outcomes from a global child obesity prevention intervention. BMC public health, 14, p.757. Pommier, J., Guével, M.-R. & Jourdan, D., 2010. Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. BMC Public Health, 10(1), p.43. Ridde, V. et al., 2012. L“ approche realist à l”épreuve du réel de l’évaluation des programmes. The Canadian Journal of Pogram Evaluation, 26(3), pp.37–59. Safarjan, E., Buis, G. & de Ruiter, S., 2013. SHE online sch ool manual: 5 steps to a health promoting school, Amsterdam: SHE Network. Samdal, O. & Rowling, L., 2013. Cross fertilization of national experiences and need for future developments. The implementation of health promoting schools. Exploring the theories of what, why and how. In The implementation of health promoting schools: the theories of what, why and how. pp. 149–161. Simovska, V. et al., 2011. Implementation of the HEPS Schoolkit: initial steps: report from the survey carried out among SHE national coordinators, Available at: http://forskningsbasen.deff.dk/Share.external?sp=S05432101-4616-408f-83fa-f7683ba8b3bc&sp=Sau. St Leger, L. & Young, I.M., 2009. “Promoting health in schools: from evidence to action”. Global health promotion, 16(4), pp.69–71. Available at: http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0007/117385/PHiSFromEvidenceToAction_WEB1.pdf. Trickett, E.J. & Beehler, S., 2013. The ecology of multilevel interventions to reduce social inequalities in health. American Behavioral Scientist, 57(8), pp.1227–1246. World Health Organization, 2008. School policy framework implementation of the WHO global strategy on diet, physical activity and health., Geneva, Switzerland: World Health Organization. Available at: http://www.who.int/dietphysicalactivity/SPF-en-2008.pdf.
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