In the Republic of Ireland, the transition from a health education model to a health promotion model by the Health Service Executive (HSE, known previously as the National Health Board) began during the 1970s. However, it was not until the mid-
41 1990s that national health and education policy began to shift specifically towards a more health promotion school model (Kelleher, 1999). In 1992, Ireland joined the ENHPS and an Irish Network of health promoting schools (INHPS) was established through a joint effort by the Department of Health and Children and Department of Education and Science, in line with the WHO guidelines (HSE, 2012). Initially, this network focused on managing a pilot project involving a number of schools that were interested in building an Irish health promoting school network. The aims of the network were based broadly on the WHO concept, and evaluation findings of the first phase of this pilot indicated that the health promoting school approach was a useful framework for addressing health even if schools found it challenging to understand how the overall mandate of health promoting school approach applied to their school (Lahiff, 2000). The subsequent recommendations arising from this research – in line with other international studies - highlighted a need for greater clarity by stakeholders regarding the concept and application of a health promoting school approach. School management and staff were also found to need more support to implement the health promoting school ethos whilst greater involvement of parents was deemed essential (Lahiff, 2000). However, despite promising beginnings in the implementation of a health promoting school framework in schools, until recently there has been little development of HPS (and INHPS) during the last decade especially at a national level. Localised networks have been set up between some schools around the country (e.g. HSE, 2009), although this has been achieved without any governmental support and are dependent on the work of dedicated local health and educational professionals rather than a national policy-led initiative.
In the early 2000s the Health Promotion Policy Unit (National Health Promotion Strategy, 2000-2005) also began supporting the Department of Education and Skills (DES) in implementing health promotion in schools through the development of the Social, Personal and Health Education (SPHE) curriculum. There are a number of parallels between SPHE implementation in schools and some components of a WHO health promoting school approach. According to the Department of Education (1999), the aims of the SPHE curriculum are: to promote all aspects of health and well-being of the child; to support children in developing respect for themselves and others in society; and to enable children to become effective decision makers. National level SPHE support services are available to assist schools in implementing the curriculum, train
42 staff and develop health-related school policies (Geary & Mannix-McNemara, 2003). According to SPHE policy, collaboration between all those involved in children’s education and health (i.e. staff, parents, board of management, health and educational professionals as well as members of the wider community), are key to the effectiveness of SPHE in addressing children’s health and well-being (Department of Education and Science, 1999). In this way it is clear that the SPHE initiative endorses a whole school approach to the improvement of children’s well-being.
There have been no independent evaluations to date of the SPHE implementation in primary schools. One study by the National Education Inspectorate (Department of Education and Science, 2009) identified the value of the SPHE curriculum and role of SPHE in the development of a positive school and classroom environment. Similarly a small number of evaluations at secondary school level indicate a number of benefits in terms of how schools address health (Geary & McNemara, 2003; NicGabhainn, O’Higgins, & Barry, 2010; O’Higgins et al., 2007). For example, school-based respondents indicated that staff training on health issues as well as the provision of the national SPHE support service2 have all positively influenced the teaching of the SPHE curriculum (NicGabhainn et al., 2010; Geary & Mannix-McNemara, 2003). In this way, the introduction, in 2000, of SPHE as a compulsory subject across schools, has been instrumental in supporting the health education component of the health promoting school approach (NicGabhainn, O’Higgins, & Barry, 2010). A similar evaluation by Miller (2003) compared schools incorporating the SPHE curriculum with schools in which the SPHE curriculum was not being taught between 2000-20013. This study indicated that, whilst all schools maintained policies on general issues affecting school life (e.g. bullying), schools which had incorporated the SPHE curriculum effectively were also more likely to have developed policies on a number of additional health- related issues specific to the SPHE curriculum (i.e. substance use, child protection, sexuality and relationships) when compared to non-SPHE schools (Miller, 2003).
2
The SPHE support service is a national service established through a partnership between the Department of Education and Skills, the Department of Health and Children and the HSE. This service provides consultation, in-school training and health-related literature to assist schools in the
implementation of SPHE 3
SPHE became a mandatory part of the curriculum in all primary and junior cycle post-primary schools in 2003.
43 These, albeit limited, findings suggest promising outcomes of the SPHE model with regard to its impact on the some areas of health and well-being of school children. Overall however, there is little evidence to indicate that the SPHE can embrace all components of the health promoting school ethos as articulated by the IUHPE (Geary & McNemara, 2003; NicGabhainn, O’Higgins, & Barry, 2010; O’Higgins, Galvin, Kennedy, Nic Gabhainn & Barry, 2007). Supporting this point, Burtenshaw (2003) argues that a health promoting school is much broader than the SPHE curriculum in the extent to which it aims to establish a health promoting school ethos. Indeed, it is clear from the evaluation studies discussed above that, besides some health policy developments, much of the SPHE work by schools has clearly focused on curriculum- based activities with the children instead of systems-level capacity-building health promotion work (i.e. addressing the whole school health ethos via the school physical and social environment, health policy work, links with the wider community, school- health service collaboration work). This indicates a preference towards a more health education model of addressing children’s health needs instead of the health promoting school approach as envisaged by the WHO. In Burtenshaw’s (2003) evaluation, there were still diverging views as to how SPHE and a health promoting school ethos were related even amongst respondents involved in the planning and coordination of SPHE. According to Burtenshaw, this lack of a shared understanding created difficulties in how SPHE has been implemented and to what extent it incorporates a health promoting school ethos.
Similarly, NicGabhainn and colleagues (2010) found that amongst secondary level teaching staff, SPHE was very much perceived as merely another component of the school curriculum. Likewise, O’Breachain and O’Toole (2013) noted a recent national shift in strategy toward a narrower curriculum that emphasises numeracy and literacy to the exclusion of other topics. This highlights the vulnerability of SPHE as a curriculum- focused approach. Additional challenges have been identified in the implementation of SPHE. For example, Mannix-McNemara (2012) highlighted that (in-career) training support for SPHE teachers is confined to 40 hours of in-service training modules and from this, staff are expected to “employ more interactive and experiential pedagogies in
their teaching.” The SPHE pedagogy is broad and far reaching, but according to
Mannix-McNemara, the training resources allocated, in themselves, indicate a lack of priority given to the SPHE curriculum (Mannix-McNemara, 2012
44 Burtenshaw’s evaluation of SPHE (2003) showed, further, that school staff also identified the lack of training when compared to other subjects as a key issue in the development of SPHE, especially given the potentially sensitive nature of the subject matter covered in the curriculum. Aside from the challenges for school staff, two evaluation studies highlight a lack of involvement by parents and children in the planning and development of SPHE (Department of Education & Skills, 2009; NicGabhainn, O’Higgins & Barry, 2010). Indeed, it was identified across a number of studies, that many parents were not informed adequately about the SPHE programme to comment on its implementation (Geary &McNemara, 2003; NicGabhainn, et al., 2010). It has also been argued that partnerships across the entire school community are essential in creating a broader SPHE school ethos (NicGabhainn et al., 2010). However, there is little evidence, to date, to indicate how democratic collaboration will occur going forward. The curriculum-focused approach, as well as the lack of collaboration with all members of the school community, highlights the differences between SPHE and a WHO health promoting school approach. However, whilst some efforts have been made to incorporate SPHE into the formal school planning structure, only limited progress has so far occurred. The perception by staff of SPHE as merely another (less important subject) further emphasises the difference between developing a health promoting school ethos and establishing an SPHE curriculum (NicGabhainn et al., 2010). The lack of reference within SPHE documents to the WHO health promoting school concept further creates difficulties in determining to what extent the implementation of the SPHE programme can facilitate the development of a health promoting school approach in Ireland. Thus, overall, it is evident that the SPHE curriculum has supported schools in addressing health issues in the classroom, but it is less clear how this work has led to schools becoming more health promoting environments. Indeed a recent guidelines document produced collaboratively between the Irish Department of Education, Health Services Executive and Department of Health (2015) states that a coordinated whole-school approach to mental health that involves the SPHE curriculum is needed. However, this document notes that such an approach should go further to also include a system of school self-audit as well as the development of effective inter-agency partnerships at both a service (i.e. National Educational Psychology Service, Health Service Executive) and governmental level (i.e. Department of Health and Department of Education & Skills) using a HPS model.
45 Whilst Ireland is a member of Schools for Health in Europe, health promotion policy in primary schools outside of the SPHE curriculum still lacks a cross-national approach in practice. Importantly, such an approach is further impeded by the nature of the Irish educational system. Whilst the Department of Education supports and resources schools, each school is led and managed by a separate Board of Management which decides the ethos of the school at an individual level. In this way, school settings can differ considerably in how the health needs of the school community are addressed. Without a national mandate, therefore, it is very challenging to implement an approach based on ethos change across schools.
Encouragingly, the Health Service Executive (HSE) in Ireland has recently established a national health promoting school strategy. A recent report on this strategic framework indicates that, going forward, national policy will endeavour to establish a health promoting school approach across Ireland as envisioned by the WHO in order to fulfil their duty of care to children (HSE, 2013). However, this framework is still in its infancy and any HPS initiatives using this framework, to date, have only been implemented in a small number of schools in, for example, the South of Ireland in County Cork. These have involved school collaboration with HSE health promotion officers to develop school capacity to address health using a health promoting schools framework. However, it is important to note that the effectiveness of this approach has yet to be established in an Irish context through a process of rigorous research and evaluation. In summary, the original aim of the INHPS to integrate the health promoting school concept with SPHE has not occurred in line with its original mandate. Unlike the UK health promoting school model, it is also evident that the health promoting school approach as conceptualised by the WHO, has only recently been embraced as a key element of Irish government policy (see HSE, 2013).