Requisitos especiales

Keshavarz et al. (2010) proposed that schools have a freedom to act, but that this is limited by a fixed set of possibilities, in part shaped by their nestedness within supra- systems described above. Inspection authorities, or at least the government

departments they represent, present an example of supra-systems that schools are nested within and which, in conjunction with broader political and economic contexts, impact upon the range of possibilities available to schools. If health outcomes such as physical activity, emotional wellbeing and hygiene were made a prominent part of inspection processes for example, this may help to increase prioritisation of health improvement activities within schools. In fact, in terms of physical activity, the Welsh Government has previously committed to giving equal weight to both physical literacy and literacy and numeracy. However, they have not fully operationalised this goal thus far (Weiler et al., 2013). The recent curriculum review by Donaldson (2015) commissioned by the Welsh Government included Wellbeing as a key factor within the curriculum going forward, whilst in England, there has been a recent tendency to move towards an ever narrower focus on educational outcomes, such as literacy and numeracy targets. Study of the interactions between systems and governing supra-systems could facilitate better understanding of school system functioning, and a better understanding of what actions schools are able to adopt within existing constraints (Stones, 2005).

49 3.4.5 Interactions within and between systems

The functioning of CASs is shaped by dynamic interactions within and between systems, sub-systems and supra-systems (Keshavarz et al., 2010). In a school context, this could apply to interactions between departments within schools, or between schools and families, communities or outside agencies (Keshavarz et al., 2010). Outcomes produced by schools are influenced by diverse interactions among agents within and between schools as well as with communities and families. Strong Structuration could be utilised to theorise these interactions in terms of the school structure and agency (Stones, 2005). Structural Hole Theory (Burt, 2004b) could theorise brokerage within and between systems and the Theory of Health Promoting Schools and Human Functioning (Markham & Aveyard, 2003) could be used to examine relationships and alignment of values between groups of stakeholders. This section will outline the importance of such interactions and their role in school-based health interventions.

CASs have permeable boundaries meaning that they work in synergistic exchange with systems outside of the school gates, such as other schools or public health organisations. Successful collaboration requires a high level of mutual trust and respect, support for joint aims and equal input from all different agencies (Asthana, Richardson & Halliday, 2002; Rummery & Coleman, 2003). Successful partnership working between these systems, sub-systems and supra-systems can present

challenges, especially where agencies, such as schools, public health and academic organisations, have different backgrounds, communication styles and language, and incentives for involvement. This highlights the need to provide schools with

evidence to establish whether by focusing on the health of their students, they are likely to achieve better exam results, and for school health researchers to attempt to understand competing pressures on schools, and develop shared mechanisms for effective communication. This may help to align public health, academic and school incentives for involvement, thus improving the chances of achieving successful partnership working and common goals (Bonell et al., 2014). This demonstrates the importance of investigating the reciprocal relationship between system structure and agency (Stones, 2005).

50 Systems are not able to be directly governed by another system, although they can observe other systems and learn and adapt accordingly. This adaptation occurs via internal rules and norms and self-organisation (Johannessen, 1998). For example, Hawe et al. (2015a) conducted qualitative interviews with control communities of primary health care teams and community agencies within an intervention to reduce post-natal depression and promote maternal health. They found systems to have adapted through lateral thinking and innovation due to being aware of the intervention but not being supported to implement it (Hawe et al., 2015a).

Collaboration with sub-systems within the school gates

Collaboration between sub-sytems: school staff

School staff form groups within complex systems which form nested subsystems, including for example, staff associated with a particular department or year group. Complex systems often have distributed control, rather than hierarchical, central leadership (Keshavarz et al., 2010). This is demonstrated by the leadership of health and wellbeing in schools, which is often delegated to another member of staff rather than the Head Teacher. Meanwhile decisions are still often made collaboratively by this staff member, administrative staff and the Head Teacher. The support of and collaboration with senior management has been found to be important for changes to be implemented in terms of health improvement in school systems (Fletcher,

Fitzgerald-Yau, Wiggins, Viner & Bonell, 2015).

Shiell et al. (2008) emphasise the need to study relational data to establish the position of key actors and collaboration within CASs, including brokerage between them, as theorised by Structural Hole Theory (Burt, 2004b). In a study of

organisational learning in a health-promoting schools network in Austria, it was found that the network only reached certain central agents, such as the school Health Promotion Coordinator, suggesting problems with information exchange within such networks and systems (Flaschberger et al., 2013). Therefore, an increased focus on organisational learning through communication and coordination within and between schools and improved resources and organisational structure are required

(Gugglberger, 2011). In a qualitative study of HPS, it was shown that school staff tended to prefer direct consultation and were reluctant to attend network meetings

51 (Gugglberger, 2011). Moreover, teachers have a tendency to strive for autonomy due to pressures to succeed and a heavy workload, which may hinder collaboration and teamwork within the school setting (Flaschberger et al., 2013). This suggests that further research to investigate how to involve the whole school in health promotion is required, and that efforts to engage schools in change processes need to attend to identifying individuals and groups who are sufficiently well positioned within their social networks to drive forward change, such as those in brokerage positions (Burt, 2004b).

Collaboration between sub-systems: Students and staff

Within CASs, students make up many key sub-systems. The importance of involving young people in health promotion has been advocated by the WHO (1998) and is central to the HPS Framework (Buijs, 2009). The Theory of Health Promoting Schools and Human Functioning (Markham & Aveyard, 2003) also advocates for breaking down barriers between staff and students, although it specifies that this does not have to be directly related to health in order to affect health outcomes. Student participation is seen as integral to the HPS whole school approach to enable students to achieve a higher level of control over health determinants (World Health Organization, 1986). Although involving young people is encouraged, there are no specific guidelines to follow. Moreover current approaches, such as school councils are often perceived negatively due to a lack of tangible outcomes and genuine collaboration between staff and students that arise from such approaches (Fletcher et al., 2015).

In support of this, a systematic review demonstrated that student councils are most beneficial for those students that are directly involved, but that all students benefit to some extent from changes to the school organisation/environment and ethos. The review concludes that student councils should be in place alongside other methods for student participation (Simovska, Griebler & Nowak, 2012). Involving young people in health promotion and ensuring that they have a voice and that their opinions are valued has been shown to increase motivation for health improvement and learning of students (Samdal & Rowling, 2011).

52

Collaboration with systems outside the school gates

Collaboration between systems: Families and schools

Families are a key external system which schools constantly interact with. Engaging families with schools is often a difficult task, especially in deprived or ethnic

minority groups (Smrekar & Cohen-Vogel, 2001). Most research into parental engagement has focused upon education rather than health. Positive effects of engaging families, such as cognitive development (Hoover-Dempsey & Sandler, 1997) and educational outcomes (Lee & Bowen, 2006), have been demonstrated. Moreover, research focused on parental involvement in their children’s education has investigated barriers and facilitators to such involvement. For example, one such study found that parental engagement was influenced the most by invitations from teachers, compared to parental resources and efficacy (Anderson & Minke, 2007). Interaction between the systems of schools and families can be theorised using the Theory of Health Promoting Schools and Human Functioning, whereby reducing the barriers and aligning values between these systems may contribute to increased student connectedness (Markham & Aveyard, 2003). Moreover, Structural Hole Theory could help to identify brokerage roles that facilitate this interaction (Burt, 2004b).

In a systematic review of the WHO’s HPS framework, Langford et al. (2014) stated that in order to have a significant impact on the health of school children, health messages need to be reinforced by parents at home. Thus parental and family involvement is also an important aspect of health promotion in schools. The review concluded that family and community engagement was often the least intensive, and least well implemented, aspect of the HPS programme compared to the focus on curriculum and school ethos and environment, and that the majority of parental engagement involved providing information to parents about health promotion efforts and advice on how to reinforce these messages at home, often via newsletter (Langford et al., 2014). Moreover, within this review (Langford et al., 2015;

Langford et al., 2014) of HPS approaches, engaging parents was reported by study authors to be the most challenging aspect. The statistics supported this, with around one third to one half of parents found to participate in interventions targeting this aspect (Langford et al., 2015). The factors affecting engagement of parents and families from lower socioeconomic backgrounds requires investigation in the UK, as

53 it is often parents who are more engaged and often those from less deprived groups who volunteer to participate in such studies (Hoover-Dempsey & Sandler, 1997).

A review of the Welsh Network of Healthy Schools Scheme (Rothwell et al., 2010) found that school staff and Healthy Schools Coordinators both perceived difficulties when trying to initiate and maintain parental engagement in Healthy Schools

Schemes. Additionally, Head Teacher perceptions of low parental commitment and even opposition to health improvement activities within the school were reported. This suggests that further research employing a complexity lens may facilitate investigation of the reasons behind low levels of parental engagement within school systems, such as lack of commitment or the manner in which parents were asked to engage (Rothwell et al., 2010).

Collaboration between systems: Other schools, outside agencies and schools

Implementation of health improvement typically depends on collaboration with agencies beyond the school gates, which may include policy and practice stakeholders, and academics. Collaboration between schools and academics is increasing, but there is a need for reciprocity in terms of support and aims (Bevins & Price, 2014).

Self-organisation refers to a tendency for the actions of agents within a system to lead to order arising spontaneously (Zimmerman, Lindberg & Plsek, 1998). Self- organisation within the health, education and political systems has been cited as a barrier to inter-system collaboration in a study of implementation of health

promotion in the Scottish school system due to the development of their own culture, terminology and methods of working (Gugglberger & Inchley, 2012). It has also been suggested that it is important to embrace complexity by collaborating with policy makers to exert influence at multiple levels as well as with organisations with similar agendas to prevent multiple siloed programmes and to exploit synergies between organisations (Dooris, 2013). These should not be restricted to programmes with a health agenda as interdisciplinary collaboration, such as between health and educational organisations, could facilitate innovation in the field and lead to whole system level change (Dooris, 2013). Dooris (2013) also highlights the need to share

54 experience and learning across organisational settings. However, barriers to such collaboration have been identified, such as personality clashes and competition between organisations (Dooris, 2013).

Gugglberger (2011) conducted a qualitative study with key stakeholders for a HPS scheme in Austria, identifying five key capacity building strategies for healthy schools. These were organising exchange among schools, using certification and quality control for HPS, offering consultation and information, carrying out health promotion programmes with specific aims and coordinating available actors and information. A study in the Netherlands developed a whole school collaborative model for needs-based health improvement (Leurs et al., 2005). This highlighted the importance of collaboration between schools and local institutions and the inclusion of school-based stakeholders, including students. Keshavarz et al. (2010) argues that schools may not communicate effectively with their environment and that there may be inadequate support and guidance for providing support for schools to do so. This may also be related to the rules and ethos within the school, which will be elaborated upon further below.