Denman, Susan; Moon, Alysoun; Parsons, Carl; and Stears, David. (2002). The Health Promoting School: Policy, Research and Practice. Reviewed by April Diana Niver, George Mason University

Denman, Susan; Moon, Alysoun; Parsons, Carl; and Stears, David. (2002). The Health Promoting School: Policy, Research and Practice. London and New York: RoutledgeFalmer. Pp. xvi + 224 $47.95     ISBN 0-415-23953-2 Reviewed by April Diana Niver George Mason University October 5, 2005 In The Health Promoting School: Policy, Research, and Practice (2002) Denman, Moon, Parsons, and Stears describe an eco-holistic model for developing, implementing, and evaluating health promoting schools, which they describe as a radical approach.. I recommend this book for teachers, graduate students, and any professional interested in public health, public policy, and evaluation research. I also caution readers, in particular readers working in the United States, to be attentive to the model’s theoretical base and the conditions that nurtured its development. The authors’ claims are grounded in a history of policies, values, theories, and strategies from the last 153 years of health promotion in the United Kingdom, which was shaped by external forces from the European Union and the World Health Organization. This text also reflects the lifetime achievements of Dr. David Stears, who died shortly after publication in October 2002. Within this review, I will discuss the authors’ description of the eco-holistic model’s theoretical base and effectiveness while being attentive to the issues and concerns I would have if I were attempting to implement such a model in the United States. There has been a shift in theoretical approaches to health promotion in the United Kingdom and in the United States. The approach recommended in The Health Promoting School: Policy, Research Practice is different from approaches found in the United States. Throughout this review, I will explicate the theoretical base for the eco-holistic model and discuss why I see it as different from approaches presently implemented in the United States. Understanding this difference is important, I believe, because attempting to utilize the eco-holistic model in the United States would present different challenges than those discussed in this text. Using an eco-holistic model in the United States would be likely to incur similar concerns of sufficient resources, sufficient training, open communication, and buy-in from participants. When addressing a question of what is in the best interest for any group there is likely to be conflict over what is best as well as competing agendas for social reform and individual gains. After reading the text, it seems likely to me that implementing the eco-holistic model in the United States would incur additional barriers related to theoretical approaches to behavior change. From my American perspective, the authors’ claims of the value of an eco-holistic model for health promotion are based on four assumptions: 1) any country serious about its future will protect the health of youth; 2) socio-economic and cultural factors can have an affect on mental, physical, and social health behaviors; 3) among youth there are alarming or unacceptable trends in pregnancy, smoking, alcohol use, illegal drug use, and minimal levels of exercise and nutrition that influence manifestations of chronic illnesses; and 5) increases in poverty are related to increases in divorce. They encourage evaluation as a means of program specific feedback and not as a means to generalizing statements or transferability. The authors present a vision of health promotion as a combination of governing policies, educational services, and clinical services targeted at improving public health conditions and physical well-being. This vision is based on World Health Organization declarations and policies. In the authors’ model, health promotion is made possible through a wide variety of methods and goals with linked resources. In their introduction, the authors explain how the last twenty-five years have seen theoretical perspectives for meeting public health needs shift toward a total environment viewand moving away from earlier lifestyle perspectives. In conjunction with this shift, World Health Organization agencies have also implemented policies supporting health promotion from a perspective that considers everyday life and environmental context in its appraisals. This book has two parts. A historical narrative arguing for the models’ usefulness is presented in the first section of the book. Substantiating evidence as well as a review of themes is offered in the second section. The narrative of historical perspectives in Part 1 explains how European and United Kingdom perspectives on health promoting schools have evolved to a new era of flexibility at local levels. The explanation rests on a history of fluctuating political support as well as from advances in research. The narrative of perspectives in Part 1 is punctuated by an examination of an evidence base for establishing effectiveness, which weaves in concepts of how to promote lifestyle changes. In the second section of the book, the authors explore findings from three case studies. The concluding discussion is a review of case study themes and the future of health promoting schools. According to the authors, national political support and funding fluctuated with changing national ecologies and economies, such as those which occurred during the Industrial Revolution, the establishment of the United Nation's and the World Health Organization's 1946 Constitution, and the 1944 Education Act in the United Kingdom. Denman, et al. (2002) argues for the eco-holistic model’s potential for building and sustaining school-student-parent-community relationships necessary for successful health promotion in schools. The eco-holistic model presented in this text varies from previous models in its attempt to have a panoramic view of system interactions, drawing from the evaluation research theories outlined by Stake (1967). It also differs from earlier models by emphasizing a balanced, collaborative approach to health promotion. This model was formed in an attempt to reduce tensions between funding institutions and grantees by reconceptualizing what counts as effective: progress or any positive change. Evidence for progress would be presented through a holistic multi-level evaluation, which would be ideally funded by at least 10% of total the budget (p. 83). The United States, similar to the United Kingdom, has a history of health promotion in public schools. Beginning some time later than the United Kingdom in this endeavor, the United States also pursued public health from a different theoretical perspective. A current distinction between the two nations can be seen intheir assumptions of the antecedents of poverty and poor health. The two nations’ policies also differ according to perceived roles of individuals and the public good. Denman, et al. (2002) state that the United Kingdom adopted a foundational assumption promoted by the Health for All initiative formed by the World Health Assembly in 1977 (p. 17). A later summary document states t health promotion is the responsibility of an entire population (p. 17). Since beginning to take on the task of educating and providing health related services to the public, both the United States and the United Kingdom have experienced fluctuations in political support and funding for public health promotion. The authors, understandably, do not discuss theory or policies in the United States, and I believe it may be useful for American readers to be aware of the differences between each nations’ theoretical approach. The eco-holistic model offered by the authors has much potential in the United States. I recommend that people who are interested in health promotion in schools or community centers be attentive to the authors’ narrative of theoretical shifts, innovations in data collection, and the influence of political and economic conditions. While the authors, Denman, et al. (2002), describe the eco-holistic model as radical, it is my opinion that federal, state, or national funding policies have a very a different approach to evaluation. If I were to go to a public school and examine any form of health education being offered, it would be very likely that the program would be based on a lifestyle approach. The lifestyle approach is based on the assumption that if a person knows what is good and right for his or her well-being and accepts the potential, positive benefits, as well as understands what behaviors are needed to ensure the behavioral practice then he or she will behave as such. This approach is regarded by Denman et al. (2002) as outdated. The authors argue for a need to transform evidence-based research from funding organizations, including governmental agencies, by stating that evaluation can not focus on one part of evaluation, such as standardized tests or assessment (p. 88). Instead, they argue for a whole-school approach targeting the entire student population and using a plethora of methodologies. Such methodologies include: interviewing, questionnaires, non-standardized tests, and standardized tests to enable a complete evaluation with several elements. According to Denman, et al. (2002) the elements of evaluation include: assessment, audit, monitoring, appraisal, quality assurance, valuation, accountability, and review (p. 88). As a student of domestic health policies and program evaluation in the United States, I have experienced frustration at the complex interconnectedness of educational, service-providing, and clinical organizations. My frustration continues as I work with teacher researchers in general k-6 classes as well as special education, art, science, anthropology, religion, math, and physical education teachers. These teacher researchers are focused on developing ways to provide evidence of positive development in student performance. The evidence they collect is intended more as a means to defend their own work in the classroom and is not accepted as evidence of success in the classroom by State Departments of Education. According to the authors, for the past 40 years, relations between health educators and funding agencies in the United Kingdom have been influenced by the United Nation's and the World Health Organization’s declarations and policies. The World Health Organization established its charter for ethical, effective, and efficient health practices in its 1946 as well as in later technical documents in 1951 and 1954 (p. 19). Before 1946, the authors claim, that the concept of health promotion was “used almost exclusively in the U.K.” (p. 16), which explains the continuous distinction they made between the health promotion or healthy schools practices between the United Kingdom and the nations on the European continent. The authors relate the history of health services such as improvements in sanitation, housing, and water with the formation of the Board of Health in 1948 and the appointment of medical experts as officers. The authority of these offices was empowered by acts of policy in 1948 and later in 1978 (p. 16). In the United States, during the 1840s, common school movements were developing and groups of medical experts where gathering to address public health concerns, particularly concerns of syphilis and other venereal diseases (Moran 2000). However the inclusion of sexual health and hygiene did not become a part of normal school curriculafor teacher training until the early 1900s. The United States first implemented a Federal policy to standardize America’s public school content and services by offering the Elementary and Secondary Education Act (ESEA) in 1965. Included in Title III of the ESEA was the acknowledgement for a need to offer family literacy education, which developed into what is commonly known as family life education . By 1971, 55 % of schools had a family life or health education program (Campos, 2002, p. 49 ). Although political support and funding for health promoting schools had withered in the United Kingdom, renewed and increasing interest since the 1970s is explained by re-examinations of progress measurements. Changes in policies and funding in the United States need further explanation. For the purposes of this review, I will speculate that part of the de-emphasis of health education in school is related to an increased interest in testing and a priority on individual responsibility and family values. . New knowledge of healthy practices may come from a school nurse or the short amount of time spent engaging with health education or family life education curriculum, which is woven into various grade levels. After considering theoretical as well as organizational differences between health promotion in the United States and the United Kingdom, I suggest American readers read Part 2 and consider what barriers or issues they may discover during program design, implementation, and evaluation. Application of the eco-holistic model in an American school poses a different set of challenges than application in schools in the United Kingdom. Complications of managing continuous channels of communication as well as a shared commitment to objectives are the largest threat to an eco-holistic model’s successful implementation or criteria attainment. The eco-holistic model attempts to include the many stakeholders involved in health promotion in public school settings, such as management, healthcare service providers, health educators, recipients of healthcare services and education, involved or concerned local community members, local or regional governance members, parents, and support staff of what counts as a worthwhile cause and what counts as evidence. Denman, et al. (2002) warn readers that implementation of an eco-holistic model will be challenging because the model is multifaceted and complex. Among the cases studied, the most prevalent constraints for growth and sustainability were attributed to schools’ organizational structures and staff commitment (p. 134). Conditions for a successful program include: the buy-in and support of coordinators, teachers, and clinicians; an infrastructure of communication, dedicated budget and resources, and the support of head teachers or senior managers and administrators (p. 137). Unable to isolate how actions observed in case research may have impacted change or development of the program, the authors emphasize how case study findings in conjunction with earlier large-scale studies and reviews of school change indicate similarity between problems experienced by small case studies reported in this text to those experienced by the larger population of state-mandated health promotion programs. American public schools and community-based organizations have not embraced the eco-holistic, or social ecology, model and focus for health promotion. For an example of America’s adherence to a focus on individual choices and lifestyle approach strategies, see the Center for Disease Control’s Healthy People 2010 goals and objectives for educational and community-based settings. The document parcels out goals specific to school settings, work-site settings, health care settings, as well as community settings and select populations. Health promotion programs in the United States should also consider professional roles as well as attitudes, values, competencies, and feelings of stakeholders—agencies, parents, students, and community leaders. People designing and/or managing a health promoting program should also consider the working relationships or participant stakeholders as well as their support of the health education curriculum if they are to try to implement an eco-holistic model of health promotion I have found that health promoting agencies are often networked to schools, other community or health promoting agencies, and state departments of health or federal funding agencies as well as juvenile detention agencies, drug counseling centers, and hospitals in my own research. Although connected and working in partnerships, most are working from the lifestyle approach and are not considering cultural or socio-economic factors. To garner a full experience of this book, I suggest that a deep reading of chapter 1, and in particular chapter 4, is necessary for understanding the evaluation framework presented by the authors in chapter 5. In chapter 5, the authors explain how longitudinal studies utilizing a range of methodologies are needed if an eco-holistic or total environment approach to health promotion is to be shown effective, appropriate, cost-efficient, and worthy of renewed funding. The authors have explained a complicated history of professional power and public accountability, making a compelling case for an “eco-holistic panorama of context, management, processes, and relationships as well as competencies and health-related behavior changes in young people” (p. 87). Some readers will find the theoretical arguments proposed by the authors to be lacking in rigor or standards based on quantitative measures. However, assessment of the eco-holistic model is intended to generate a profile of processes or baseline data. The profile, based mainly on qualitative data gathered through questionnaires and interviews, can be used to establish whether objectives or criteria have been attained. Denman et al. (2002) provide a strong theoretical base for a complex design of social networking and its evaluation. The goal of the evaluation is realistic, asking that programs not be judged in terms of reaching a standardized point in a predetermined amount of time. Instead, they argue a program should be assessed on whether or not the program has shown improvement, considering its unique conditions of internal and external forces. Published in 2002, The Health Promoting School: Policy, Research, and Practice and its authors have changed centers and continued their work on health promoting models. As an aside note, I would like to alert interested readers that there is a change in the location of a reference text offered by the authors. Guidelines on specific techniques for evaluating health promoting schools can now be accessed at http://health.canterbury.ac.uk/CHER/. A complex network of health service agencies and educational settings—including billboards, public service announcements, in-school curricula, pamphlets, etc.—is different from an eco-holistic model when it is guided by a lifestyle approach to behavioral change. I agree with the authors that informing people of what constitutes a healthy choice and finding that people agree that a healthy choice is a positive thing, but itdoes not necessarily increase the probability that these same people will make healthy choices. The eco-holistic model is a radical model because it is suggesting that if people are not making healthy choices, are not acting in their own best interest, then perhaps it is the responsibility of the health provider and health educator and the general public to work together to find better or more feasible choices. Readers will differ in their theoretical approaches to health promotion. For example, they may approach health promotion through lifestyle choices or conditions according to settings, rather than a more process-oriented theory. I recommend this book to people in various disciplines and approaches because of the excellent history of theory in evaluation. The Health Promoting School will assist teachers, graduate students, researchers, and professionals addressing challenges posed by conflicting priorities in public health. References Campos, D. (2002) Sex, Youth, and Sex Education: A Reference Handbook. Santa Barbara, CA: ABC-CLIO. Center for Disease Control. (December 16 2004). NCHS -Healthy People 2010- About Healthy People 2010. July 12 2005. http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm Center for Disease Control. The Healthy People 2010. Center for Disease Control. August 2, 2005. http://www.healthypeople.gov Kuhn, T. (1996). The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press. Mooney, Elizabeth. The School’s Responsibility for Sex Education. Bloomington, IN: The Phi Delta Kappa Educational Foundation, 1974. Moran, J. P. (2000).Teaching Sex: The Shaping of Adolescence in the 20th Century. Cambridge: Harvard University Press. Office of Elementary and Secondary Education.About. July 24 2005. http://www.ed.gov/about/offices/list/oese/index.html?src=rt Stake, R. (1967). “The countenance of educational evaluation.” Teachers College Record. 68: 523-40. Tones, K. (1981) Health Education: Prevention or Subversion?, Royal Society for Health. 3: 114-117. About the Reviewer April Diana Niver is also an Instructor of Education in the Initiatives in Educational Transformation at George Mason University. Her current research focuses on the lived experiences of sexuality and abstinence educators in the United States. Copyright is retained by the first or sole author, who grants right of first publication to the Education Review.