CUMPLIMIENTO DE LOS INFORMES EMITIDOS POR EL MINISTERIO DE MEDIO AMBIENTE

The study setting was an area previously designated for “Coloured”5 people in Cape Town. The Western Cape is the only province in the country which has a majority of “Coloured” people as compared to “Blacks” in the other provinces. The majority of people in this resource-limited area

5 _{“Coloured” refers to one of the racial groups as classified during the apartheid era.}  

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in Cape Town is still “Coloured” which means that they have remained on after democracy. One of the reasons could be that they could not afford to move to other better resourced areas

reflecting the inequalities described earlier.

The information included in this section is mainly related to factors that could potentially influence specifically the youth in the community, and is by no means a comprehensive

description of the community context as a whole. Although the schools are in close proximity to each other, according to the 2011 Census (StatsSA, 2012), they are located in different sub- places6 and therefore the related statistics are presented separately. Consequently, I present different sets of statistics for the three sub-places in which the schools are situated. I have named the sub-places Place A in which School A is located, Place B which School B is located, and Place C in which School C is located. The socio-demographic information was sourced from the City of Cape Town.

It is apparent from the statistics in Table 1 that the area within which the schools are situated is a resource-limited setting. However, Place C is poorer still in terms of employment and education levels. Many residents in the broader area live in formal but small sub-economic housing, and even in informal structures put up in the yards of these houses, leading to overcrowding on the premises. There are also a number of blocks of flats (usually three to four storeys high) which are owned by the local municipality and rented out to the residents. However, these buildings are poorly maintained and have no fenced off areas or gardens. On the other hand, there are also well maintained houses with gardens and fences reflecting the range of socio-economic status in the community, from deprived to relatively affluent. All the formal houses and flats are supplied with electricity, running water and flush toilets. The informal structures on the premises usually make use of the same services. Place C, unlike the other two places, is situated in an industrial area, which means that the risk of air pollution is higher there. Furthermore, the airport is

situated very close to the broader area and the noise of planes flying overhead throughout the day is a reality for all the schools in the area.

6_{Sub-place is term that StatsSA uses to delineate geographic areas. Statistics are given for specific sub-places.}  

23 Table 1: Socio-demographics of study site

Socio-demographics % of total population of Place

Place A Place B Place C

Race: Coloured 94% 93% 90%

10-24 years age group (largest group of total place population) 26% 27% 27% Employed 51% 54% 35% Majority monthly income R6401-R12 800=24%* R3201-R6400=22% R6401-R12 800=25% R3201-R6400=20% R3201-R6400=28% R1601-R3200=24% Education level: Grade 12 Higher (tertiary) education 30% 10% 26% 20% 22% 1% Formal dwelling 93% 82% 89% *R1=$0.8 as at 1/07/2015.

The community has access to different amenities and organisations providing services in the area. There are a few play parks in the area but all have been vandalised. These play areas are not regarded as safe for children because homeless people gather, drink alcohol and sleep there. The recreational facilities in the area include a sports stadium, and a public swimming pool, which charges an entrance fee. There is also a public library. There are two primary healthcare clinics, one secondary hospital and a tertiary hospital in the vicinity of the schools. Christianity is the main religion practiced. The numerous churches in the area have church members who are active in the community. For example, they run feeding schemes in the community and have

programmes for the youth. There are also several NGOs in the area that provide a range of social services to improve conditions in the community. For example, one such organisation’s focus is on crime prevention and targets gang members and past offenders (Bonn, Gobhozi, & Krieger, 2001; Fakier, Ismail, & Malope, 2011).

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The 10 to 24-year age group is the largest group of the population in the area (StatsSA, 2012) which means that a large proportion of them are attending school, which is consistent with the rest of the country. However, the students in this community face violent crime on a regular basis as reflected in the following statistics for April 2013 to March 2014 (see Table 2) from the two police stations serving the area (South African Police Service, 2014). These are actual numbers of the crimes committed. Many of the violent crimes as illustrated by the statistics in Table 2 can be related to gangsterism, which is rife in this area. According to a report for the Institute of Security Studies, (Standing, 2005), there were 130 gangs operating on the Cape Flats (the areas which were allocated to mainly coloured and black people) with a membership of approximately 100 000. The following extract from the Standing (2005) report sums up the community context in which the schools in this study are located:

…it has become common for large numbers of gang members to fight openly on the Cape Flats using a frightening array of weaponry. These gang wars have turned communities into battlegrounds and stray gunshots have claimed the lives of several innocent bystanders. (Standing, 2005, p. 2).

Most often, it is the youth and the vulnerable, especially those with unstable families, who are recruited into the gangs with the promise of material and financial support, and drugs. In fact, a large part of the gangs’ income is derived from drugs (Standing, 2005). The threat of

gangsterism and exposure of the school children in the area to drugs and violence is therefore very real (Standing, 2005; Waterhouse, Frank, & Kelly, 2007). For example, in a study on secondary school students in Cape Town, Plüddemann, Flisher, Mcketin, Parry and Lombard (2010) found that methamphetamine use in addition to other substances was significantly associated with non-attendance at school. The use of methamphetamine has increased

dramatically since 2006, especially in Cape Town. It was found that a large proportion of the methamphetamine patients admitted for treatment were adolescents, and concern was raised because of the serious side effects that can affect the cognitive development of adolescents (Plüddemann, Myers & Parry, 2008).

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Table 2: Crime statistics in the study area (actual numbers)

Crime Police station

(serving Place A) Police station (serving Places B and C) Murder 40 60 Sexual crimes 75 96 Attempted murder 75 180

Assault with intent to do grievous

bodily harm

319 342

Common assault 411 546

Unlawful possession of firearms and ammunition

82 94

Drug-related crime 1315 1355

Driving under influence of alcohol or drugs

95 160

It is evident that the community context within which the study schools are located poses a challenge to the health and well-being of the students attending these schools, their families and the teachers. For example, the broader area within which the schools are situated has one of the highest prevalences of TB in the world (Den Boon et al., 2007). Poverty, high rates of

unemployment and the violent crime noted above also contribute to the challenges facing the youth. Furthermore, problems of alcoholism, HIV and AIDS, and TB (den Boon et al., 2007; Reddy et al., 2010) can contribute to poor academic performance. As stated earlier, as a result of the inequities of the past in SA, including an inequitable school system along with insufficient investment under the current government, resources and infrastructure at historically

disadvantaged schools are still inadequate (van der Berg, 2008). Despite interventions to bring about transformation in schools, inequities still exist resulting in different educational outcomes (Bloch, 2009). Youth at these schools are poorly equipped to deal with the many challenges that they face in the community. The schools in the study area reflect the socio-economic and societal conditions outlined above, as well as the particular circumstances relating to the study schools themselves.

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All public schools in SA are categorised into five groups (or quintiles) according to the economic status of its population, largely for the purpose of allocating financial resources. Quintile 1 is the “poorest” group of schools, while Quintile 5 is the “least poor”. Quintile 1 to 3 schools are no- fees-paying schools. These poverty rankings are determined nationally, according to the poverty of the community around the school as well as certain infrastructural factors. However, the allocation of this system does not always work as parents of children in fee-paying schools in this study often could not afford the fees. All three schools in the study are classified as Quintile 4, or fee-paying, schools. From my interviews with the principals and teachers, it is clear that not all the students pay their fees because some genuinely cannot afford it. The perception also exists that others can afford it, but do not prioritise school fees.

The three schools were similar in certain aspects but also differed in others, which meant that the context within which HPS was implemented differed from school to school despite them being in the same geographical area. The profiles of the schools are presented at the beginning of each case, which is described individually in the Findings chapters.

1.7 PROBLEM STATEMENT

Although health promotion in schools has been in existence since the 1980s (Samdal & Rowling, 2011), there has been insufficient examination of the process of implementing HPS and the factors that influence this process. There is, however, a proliferation of literature on the value and effectiveness of the HPS approach, especially at the level of influencing the individual (student and teacher) and of the success of health promotion programmes that address specific health problems in schools, as indicated earlier. This is exemplified in three systematic literature reviews, which found that many studies aimed to identify whether the HPS interventions worked or not, without looking to see what was actually involved in the process of implementation: these were also mainly quantitative studies (Deschesnes, Martin, & Hill, 2003; Mũkoma & Flisher, 2004; Steward-Brown, 2006). Furthermore, while there is some discussion in the literature (Aldinger et al., 2008; Keshavarz, Nutbeam, & Rowling, 2010; Rowling & Jeffreys, 2006) about the challenges and facilitators of implementing HPS, and the recognition that they are complex systems (Keshavarz et al, 2010), there is insufficient evidence that untangles the complexities of

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these influencing factors. This suggests that there is insufficient documented evidence about the positive opportunities, or enablers that could be built on, or the challenges that need to be adequately addressed. In other words, HPS initiatives continue to struggle without sufficiently learning from the lessons of previous experience.

Furthermore, there are few international studies on HPS that have focused specifically on secondary schools (Lowe, Balanda, Stanton, & Gillespie,1999; Lynagh, Knight, Schofield, & Paras, 1999; Moon et al., 1999). Yet many problems faced by secondary schools are very different from those that affect primary schools, and need to be addressed in a different manner (Lynagh et al., 1999).

1.8 PURPOSE OF STUDY

Fixen, Naoom, Blase, Friedman, & Wallace (2005, p. 5) define implementation as “a specified set of activities designed to put into practice an activity or program of known dimensions”. As opposed to an event, it can therefore be seen as a process with organisational change taking place (Bertram, Blase, & Fixsen, 2013). Similarly Greenhalgh, Robert, Macfarlane, Bate, &

Kyriakidou (2004, p. 582) describe implementation as “the active and planned effort to mainstream a new intervention within a practice organization” and emphasise the focus on process instead of outcomes, which fits well with the notion of HPS, conceptualised as a process and an approach rather than an event. Weiner, Lewis, & Linnan (2009), writing of

implementation generally, recommend further research that will inform the implementation of complex innovations. Discussing organisational settings, Dooris & Barry (2013, p.17) suggest that “… implementation research enhances our ability to map out the critical connections

between the local context, intervention activities and the intended and intermediate and long term outcomes”. These authors reinforce the importance of examining the process of an innovation like HPS.

According to Samdal & Rowling (2011), research on implementation may be an important initial step in helping to identify the key implementation components for HPS, in order to effect good practice. The need for research evidence on the HPS implementation process is especially needed from developing countries. Specifically, to date, there is a lack of evidence of the

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implementation of HPS in SA, despite its operation for many years, which is one of the key motivations for this study. In the light of the likelihood that the HPS approach is likely to be advocated in SA into the future, and the dearth of evidence of what elements of implementation drive and challenge success, it was therefore resolved to study the HPS implementation process and the complexities related to it in order to make recommendations specific to secondary schools in SA but also beyond. The particular UWC HPS project that forms the basis of this study was implemented as a pilot project in three secondary schools in a resource-limited setting in Cape Town, SA. The purpose of this study was to explore and understand the factors

influencing the HPS implementation process and the complexities related to these factors.

1.9 OUTLINE OF THESIS

Chapter 1 provides the introduction to the thesis. The background to this study is shared to contextualise the focus of this study in the field of HPS, and to inform and familiarise the reader with the realities that schools and the youth in SA face. The situation of HPS in SA follows. A description of the UWC HPS project on which this research is based is then given, followed by an illustration of the study setting. The statement of the problem is then articulated, with its related research purpose.

Chapter 2 gives a review of the literature on the key factors influencing HPS implementation. It has five key areas, focusing on facilitating, as well as challenging factors influencing the

implementation of HPS or health promotion innovations in schools. The first key area is related to the whole approach to HPS which is followed by the contextual factors that influence HPS implementation. School leadership and management factors are presented as the third key area, and is followed by participation in HPS. The final key area is on various collaborations for HPS implementation.

Chapter 3 introduces a conceptual framework for this study. An overview is given of the concepts, approaches and frameworks that could be applied in the implementation of HPS in order to develop an analytical framework for this study. The settings approach to health

promotion is discussed followed by a description of the implementation components that inform the adapted framework developed to facilitate the analysis for this research.

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Chapter 4 provides an overview of the methodologies used in this research, and includes the research aim and objectives. An overview of the qualitative research design and the rationale for the choices made is given next, followed by an explanation of the study population and sample, including the sampling procedure. The data collection methods and tools are described next, followed by an explanation of how the data were analysed. A discussion of the quality of the research follows by expanding on how the rigour of the study was ensured. Finally the ethical considerations are highlighted.

Chapter 5 is a short preliminary chapter providing an introduction to the findings in chapters 6, 7 and 8. It explains the outline of the findings chapters and emphasises the uniqueness of each case. It also includes the key common factors across all three schools.

Chapters 6, 7 and 8 present the findings that emerged from multiple sources and data collection methods used for this research. Each chapter describes an individual case. A detailed description of factors influencing HPS implementation in each school in their particular context is given as a case. The description follows a similar format for each case and is based on the adapted

framework.

Chapter 9 integrates the findings of the study and consists of a discussion of the findings. It highlights the five main categories that emerged in the data analysis, namely: external contextual factors influencing HPS implementation; factors influencing integration of HPS as a whole- school approach; factors influencing student participation; the UWC team as external catalyst for change; and perceptions of HPS sustainability. The main issues in the literature in relation to these categories are explored and aspects that concur, deviate from, or contradict previous research and literature, are noted and discussed.

Chapter 10, as the final chapter, consists of a summary of the research, the key findings and conclusions from them, the significance of the study and the recommendations that emerged from the findings. Finally, suggestions for further research are made.

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2 LITERATURE REVIEW