CARTOGRAFÍA Y TOPOGRAFÍA

The HPS approach draws on the Ottawa Charter as its framework and includes: developing healthy school policies; creating healthy social and physical environments at school, building individual health skills and action competencies; making community links; and accessing services appropriately and effectively (IUHPE, 2009; World Health Organization, 1998). These action areas indicate that an integrated and coordinated approach needs to be taken to implement HPS. In order to achieve this, the whole-school approach has been promoted. Studies have shown the value of a whole-school approach for addressing the health and well-being of the school community (e.g. Nilsson, 2004; Patton, Bond, Butler & Glover, 2003; Poland, Krupa & McCall, 2009; Wyn, Cahill, Holdsworth, Rowling & Carson, 2000) including the

implementation of HPS (Deschesnes et al., 2003; Samdal & Rowling, 2011; 2007; World Health Organization, 1999; World Health Organization, 2007b). According to Clarke, O’Sullivan and Barry (2010, p. 275): “The many factors which affect programme implementation are whole- school practices whose particular combinations create a unique school culture within which programme implementation occurs”. Weare and Markham (2005) claim that the whole-school approach is synergistic with the HPS approach because it regards health as a holistic concept and aspires to the comprehensive HPS principles. Similarly, Nilsson (2004, p. 74) concludes that: “When focusing on participation and democracy, health promotion work and school

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development becomes allied with one another …”, even though they come from different paradigms.

It has been recognised that the school system is complex, with hierarchical multi-components including, but not limited to, the school structure, ethos and climate of the school, curriculum, dynamic relationships of teachers, students, parents, the community, district officials and other agencies (Gregory et al., 2007; Inchley et al., 2000; Keshavarz et al., 2010; Waters, Cross & Runions, 2009; Weare & Markham, 2005). From a systems thinking perspective, a whole-school approach takes a multi-level approach, which involves all the sub-systems in the school system (Donald, Lazarus, & Lolwana, 2002). HPS, as whole-school approach, places great emphasis on creating an environment that is health promoting for all participants and, at the same time, sees to the needs of individuals in the school community (Wyn et al., 2000). This approach promotes the combination of top-down strategies from leadership and management, such as policies, and bottom-up strategies, where those targeted for the intervention actively participate in the process (Larsen & Samdal, 2008; Nilsson, 2004).

However, despite the rhetoric of employing the whole-school approach for HPS, several studies have found it challenging to achieve (Adamowitsch, Gugglberger & Dür, 2014; Kremser, 2011; Wyllie, Postlethwaite and Casey, 2000). These findings are supported by Gard and Wright (2014, p. 113) who state that “There are clear signs around the world that school-based public health interventions are heading in a more instrumental, individualistic and even punitive

direction”. This statement is supported by earlier findings on HPS such as the systematic review of Lister- Sharpe, Chapman, Steward-Brown, et al. (1999), the narrative synthesis of Rowling and Jeffreys (2006) and the very recent findings of Moynihan, Jourdan, & Mannix McNamara (2016) who claim that success was only shown in some discrete areas in schools in Ireland, such as healthy eating, but coherent whole school implementation of HPS was not very evident. A common trend is that “traditional topic-based approaches” (Adamowitsch et al., 2014, p. 13) are implemented but the HPS approach is not integrated into the functions and culture of the school, and therefore widespread transformation in the school does not often occur (Kremser, 2011; Steward-Brown, 2006). Woodall, Warwick-Booth, & Cross (2012) contend that concept of empowerment in health promotion has been “diluted” because of the shift of focus in health

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promotion from the population level to the individual level encouraging a reductionist approach rather than endeavouring to focus on broader social and structural changes. This focus on the individual has led to personal empowerment (although also important) rather than empowerment at the community level. It has been argued that integration can be better achieved if HPS is not implemented as discrete activities but is rather perceived as being a core element of the school, in keeping with a whole-school approach and considered for its added value for learning and development (Aggleton et al., 2000; Inchley et al., 2007).

2.2.1 Integration of HPS as a whole-school approach

The importance of aligning the HPS approach to the broader mission of schools with their educational and social outcomes and ongoing school improvement has been emphasised for HPS integration to occur (Hoyle, Bartee & Allensworth, 2010). This will ensure that the innovation is not regarded as an add-on but rather as another way of doing what they are already meant to be doing (Hoyle et al., 2010). Richardson (2007) highlights the fact that, no matter how well a plan is conceived by the health sector, if it does not align with the goals of the education sector, it will be a challenge to implement it in schools. However, one of the main challenges that has been identified by many studies for integrating HPS, is the competing academic priorities for schools, with many regarding HPS as an “add-on” to their already full academic schedules, and the continuous changes demanded by the education authorities (Aggleton et al., 2000; Aldinger et al., 2008; Deschesnes, Couturier, Laberge & Campeau, 2010; Inchley et al., 2007; Rissel & Rowling, 2000).

For example, Clarke et al. (2010) found that finding the space, time and resources to support HPS implementation in an already overburdened timetable was difficult. Teachers are often in survival mode at school because of the academic demands on them, thus impacting on the time that schools can devote to HPS implementation. Gugglberger (2011) found that teachers did not have time to plan for HPS, and therefore preferred to be told what to do so that they could just implement actions, contradictory to the HPS approach of participatory and collaborative

working. In addition, teachers’ deferral to external stakeholders because of their expertise can be seen as a way of relieving the teachers of some their duties (Rowling, 1996). However, according

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to (Rowling & Jeffreys, 2000), this reliance on external stakeholders suggests that there might not be ownership at school level, which is important for integration and sustainability.

Several other challenging factors have been identified for integrating HPS, and include lack of co-ordination, collaboration and commitment of different partners and structures, limited leadership and management support, lack of understanding, and lack of political will (Adamowitsch et al., 2014). Some of these factors will be discussed further in subsequent

sections in this chapter. One key area of focus is the contextual factors which have been found to have a significant influence on the implementation and integration of HPS.