CONCLUSIONES  ASOCIACIONES PALEONTOLÓGICAS

Schools provide an ideal opportunity for improving nutrition, increasing physical activity and reducing obesity among children (Reniscow, 1993; Story, 1999; Wechsler, Devereaux, Davis, & Collins, 2000). Children have intensive and continuous contact with schools during the first two decades of life (Reniscow, 1993). They eat one or two meals a day at school, including snacks and foods from the school cafeteria and vending machines (Reniscow, 1993; Wechsler, Devereaux, Davis, & Collins, 2000). School is, therefore, an environment within which children can learn and practice positive nutritional behaviours (Reniscow, 1993). There are also numerous resources available for physical activity, including gymnasiums, sports fields and play areas. Children have

opportunities to participate in physical activity during PE classes, recess periods and through extracurricular sports (Story, 1999; Wechsler et al., 2000).

School is also a supportive environment in which to implement nutrition, physical activity or obesity reduction promotions. Teachers and peers can act as role models (Wechsler et al., 2000) and provide social support for students (Reniscow, 1993). School nurses support children through the provision of screening (e.g. vision, hearing, dental hygiene) and behavioural counselling services (Reniscow, 1993; Story, 1999). Additionally, school-based health promotions can be of little or no cost to families, enabling exposure for children from low income families which other (e.g. clinical) programmes may not reach (Story, 1999).

2.2.2.

The Health Promoting Schools (HPS) Initiative

The HPS initiative11 _{employs a holistic approach to health promotion, where health is}

incorporated into all aspects of school life. A HPS is one constantly strengthening its capacity as a healthy setting for living, learning and working (World Health Organization, 2003b). The HPS framework does not focus on any one element of health (e.g. nutrition, physical activity, mental health), but rather provides a model which allows schools to identify and address health issues important to them and their community. The HPS initiative is regarded by the New Zealand Ministry of Health (2001) as an effective means to improve children‘s health and the HEHA strategy, therefore, recommends schools implement the HPS model.

An evaluation of the New Zealand HPS pilot project, involving schools in Northland and Auckland, was conducted during 1998-2000 by Phoenix Research, as documented by Wyllie, Postlethwaite and Casey (2000). The objectives of the evaluation were to gain understanding of the impact of HPS on schools and their communities, and to discover key dimensions for success of the initiative. Evaluation methods included interviews, a self-completion survey and focus groups with selected HPS stakeholders such as HPS coordinators, regional coordinators, public health nurses and HPS managers. Only perceptual and attitudinal data were collected; behaviour change as a result of the interventions was not measured.

Evaluation of the pilot project showed support and involvement from key stakeholders, such as principals, Board of Trustees (BOT) members, school health coordinators, HPS coordinators and public health nurses was vital to successfully implementing the initiative (Wyllie et al., 2000). Sufficient training for HPS coordinators was also important, as was the formation of a health team

11 _{The concept of the 'Health Promoting School' emerged from complex innovations in Europe and North}

America in the 1980‘s (L. St. Leger, personal communication, July 08, 2009). The concept was developed and refined at a European symposium entitled 'The Health Promoting School', which took place in 1986. Young (2008) states the name 'The Health Promoting School' was in fact born during the planning of the event, although the concept had been evolving for several years.

within the school (usually consisting of the principal, HPS facilitator, parents and students). Other critical success factors included stakeholders having a clear understanding of what they were undertaking and a high level of commitment to the project (Wyllie et al., 2000).

No further evaluation studies of the New Zealand HPS initiative have been conducted. HPS has, however, been reviewed in research conducted for Auckland Regional Public Health Service (ARPHS) (2006) regarding childhood obesity prevention programmes. The ARPHS research identifies potential problem areas for HPS. These include a need for schools focusing on obesity prevention to clearly state their objectives and measure appropriate outcomes. There are also a limited number of schools involved in HPS and few multi-lingual resources (e.g. in Māori and Pacific Island languages). Communication difficulties among HPS facilitators and their school communities is another issue, as is the need for a comprehensive approach to programme delivery. Additionally there is a need to align health promotion activities with the curriculum in order to receive Ministry of Education support.

Several issues become apparent when the HPS evaluation and the ARPHS review are examined. First, these are the only studies to date regarding the HPS initiative in New Zealand, yet the HPS framework is promoted by the Ministry of Health as an ideal model for effective health promotion. Clearly, more research regarding HPS would be beneficial for stakeholders promoting and/or implementing the initiative. Second, the two studies indicate communication processes are an important influence on the implementation and outcomes of school-based health promotions. Findings of the HPS pilot evaluation and the ARPHS review are thus important to this thesis as they validate the need for research exploring communication processes within school-based health promotions, particularly communication approaches used by HPS. Furthermore, this study is likely to make a valuable contribution to local HPS knowledge as there is little New Zealand-based research.

2.2.3.

Success of School-Based Health Promotions

A robust and growing body of literature indicates successful public health promotions and campaigns are those which utilise social marketing techniques and are underpinned by theory. Evaluation studies of school-based health promotions, however, often report disappointing results. The suggestion is that school-based health promotions increase knowledge, but rarely produce significant long term behavioural changes (Atkinson & Nitzke, 2001; Lister-Sharp, Chapman, Stewart-Brown, & Sowden, 1999; Warren, Henry, Lightowler, Bradshaw, & Perwaiz, 2003). This indicates that current educational strategies for health promotion are not achieving transformations in children‘s eating and physical activity behaviours. By way of explanation, Warren et al. (2003) suggests health promotion in schools requires replication in other social settings, such as the home

environment, to increase effectiveness. Success of school-based health promotions is likely to be dependent on numerous other factors too. Contento, Randell and Bach (2002), for instance, completed a comprehensive review of nutrition education interventions and found dietary change was dependent on personal motivations and sense of relevance of the change, as well as judgements of resources needed to do so and willingness to overcome barriers. Environmental change in the availability, accessibility and affordability of food (e.g. in school tuckshops and the wider retail environments), social and cultural norms, and community assets and empowerment (e.g. resources and collaborations) were also important. Other success factors in the implementation of health promotions, and the subsequent success of those promotions in changing behaviour, may include professional development for school staff, high levels of commitment and communication among stakeholders, and the ability to allocate sufficient time to health promotion processes (Wyllie et al., 2000). Schools also require support in terms of funding (Mukoma & Flisher, 2004; Wyllie et al., 2000), partnerships and resources (Deschesnes, Martin, & Hill, 2003; Wyllie et al., 2000).

The international body of literature pertaining to school-based health promotions continues to grow. In the course of this review, however, no studies were found which examined communication among stakeholders or communication processes in the delivery of school-based health promotions. This absence of literature, again, presents a significant knowledge gap, validating the need for my research on this topic. As indicated by Wyllie et al. (2000), implementation of health promotion programmes is dependent on effective communication among stakeholders. The focus is often placed on tailoring messages to the end user target group (e.g. children as a homogenous group, or sub-groups, such as junior or senior school children). Yet there is little consideration of communication processes: how communication takes place among all stakeholders (e.g. external promotions organisers and schools; teachers and parents) for the implementation and delivery of promotions. Communication may impact on whether stakeholders buy-in to health promotions, what strategies they adopt, how promotions are implemented, and what effect promotions have on children‘s health knowledge, attitudes and behaviour. Communication processes within school-based health promotions are, therefore, worthy of investigation as they potentially impact significantly upon the success of those promotions.

We now know communication processes are an important yet under-researched influence on health promotions. We know from a social marketing perspective, communications are used to promote ideas and behaviours among a target group. We also know that IMC offers a coordinated approach to communication efforts. My research, therefore, explores communication processes within school-based health promotions, but offers research differentiation by using a marketing perspective and applying marketing communications principles in a social marketing context.

2.3.

Communication Theory

Communication theory is central to this research on school-based health promotions. The term communication can refer to a variety of activities and as such has multiple definitions (Frey et al., 2000). Communication can be viewed, for example, in the context of interpersonal communication, organisational communication and mass media communication among many others. Communication is derived from the Latin word, communis, meaning ‗to make common‘. Although, there are multiple definitions of communication, most focus on one or both of the following two themes; communication as the transfer of information, or communication as the generation of meaning (Frey et al., 2000).

In this research, communication, as both the transfer of information and the generation of meaning, is considered in the context of marketing and health. As explained previously in section 2.2 of this chapter (p.11), marketing communications are brand-focused, designed to facilitate exchanges with the brand‘s target audience by sharing the brand‘s meaning and differentiating the brand from competitive brands (Shimp, 2003). In health, communication refers to activities which are directed towards improving the health status of persons and populations. ―Health communication may involve the integration of mass and multi-media communication with more local and/or personal traditional forms of communication‖ (Nutbeam, 1998, p. 355). For the purposes of this study, a marketing communications process is used to examine communication designed to promote health. Models of marketing communications processes are discussed in the following section.