The way to a healthy school is through it's stomach: food and nutrition as an entry point to a Health Promoting School. David Spillman Gabrielle Baker Assistant project manager Project officer National Nutrition Education in Schools Nutrition Education and Teenagers project project Centre for Public Health Research QUT GPO Box 2434 Brisbane Q 4001 Abstract The justification for the inclusion of health, and therefore food and nutrition, education within the school curriculum has traditionally revolved around the belief that schools have an obligation to assist individuals to develop knowledge, attitudes, beliefs and skills to be able to improve their health-related behaviour, both in the short term and for the remainder of their lives. While recognising the importance of this rationale, other complimentary arguments are currently being proposed. In particular, there is an emerging body of support, both philosohpical and research-based, for the notion that the degree of health within a school community, which includes the health of individuals, groups and environments can have a dramatic impact upon the educational outcomes achieved by students within that community. Secondly, health and in particular food and nutrition has been implicated as a critical social equity issue within school communities. To adress a rationale based upon such a combination of arguments requires school communities to consider more than just the health curriculum. The Health Promoting School model provides a framework for such development. Case studies of four schools involved in the Nutrition Education and Teenagers project (NEAT) will be refered to in this paper to provide support for the hypothesis that food and nutrition is an efficacious point of entry into the Health Promoting School model. Introduction: In 1991 funding was made available for the development of a national network of Health Promoting Schools (Ackermann 1991). At the 1992 AARE conference held at Deakin University the National Association for Healthy School Communities was founded and the inaugural meeting convened. Although the Health Promoting School model had already been used as a developmental framework in some Australian schools prior to these events, the formation of these organisations represented the first initiatives in developing a national support network for these schools. In the twelve months that have elapsed since then a number of related publications based on Australian school experiences have become available with others currently in press, marking an emerging interest in this holistic approach to school community-based health. Health promotion has been described as, the process of enabling people to increase control over, and improve, their health. It represents a mediating strategy between people and their environment, synthesising personal choice and social responsibility in health to create a happier future (Green and Iverson 1982) Thus health promotion focuses upon optimising the attainment of both individual and collective wellbeing. This is approached through the proactive efforts of individuals, groups and organisations with regard to health practices, policies and structures. As suggested above, central to such an approach is the consideration of the relationships between individuals, groups and their environments. Thus the underlying philosophy which provides a foundation for health promotion borrows concepts from models such as 'self-empowerment' and 'collective action' (Colquhoun 1992) as well as those emanating from the field of social ecology (Stokols 1992). In pragmatic terms and, related to schools, health promotion has often been described as a combination of health education and "all other actions which a school takes to protect and improve the health of all those within it" (Young and Williams 1989). Whilst this description identifies that health promotion within schools means more than the health curriculum it provides no elucidation regarding the types of non-curricula activity and therefore may serve to oversimplify or trivialise these "other actions". The Health Promoting School model focuses upon three essential and inter-related components. These are the health education curriculum, the social and physical environments of the school and the relationships between home, the community and the school (Young and Williams 1989). The health education curriculum should be both comprehensive and sequential, embracing relevant health issues in ways appropriate for the students level of cognitive development and relevant to their experiences. The social and physical environment has also been termed the "school ethos" or "hidden curriculum". It embraces the non-formal happenings in the school including "the atmosphere of the school, its code of discipline, the prevailing standards of behaviour, the attitudes adopted by staff towards pupils, and the values implicitly asserted by its mode of operation" (Young and Williams 1989, p19). The third essential element is the relationship between home, community and the school. This partnership is essential in promoting consistent messages to children with regard to health and education. What's in it for schools? Traditional justifications for the inclusion of health education within the school curriculum have revolved around the perceived role that education institutions can play in assisting individuals to improve their health. Theories used by health educators in the fifties and sixties were based upon concepts of effective transmission of knowledge and were primarily concerned with the quality of communication to audiences. The belief was that "information given in an optimally persuasive manner" would result in modification of attitudes which would lead to changes in behaviour (Bunton et al 1991). More sophisticated behaviour change models and theories which identified critical factors affecting health behaviour were developed in the seventies and eighties. The selfempowerment model which emerged in the eighties focuses upon empowering individuals to take control of their behaviours (Colquhoun 1992). Despite their increasing refinement all these models contrive to focus primarily upon individual behaviours and the role that education can play in the development of personal health. More recently attention has been drawn towards the effects of inequitable access to health resources and facilities on the health options and status of individuals and groups. In particular it is now well accepted that certain individuals and groups of people may not be able to create changes in their health behaviour because of diminished access to the resources and facilities necessary for such changes (CDHHCS 1992). Consideration of such social justice issues with regard to health encourages schools to direct attention towards their own social and physical environments to ensure equity of access to resources and facilities (Nutbeam et al 1993). In addition, there is, amongst health educators and researchers, an increasing attention being directed towards the effect of varying levels of health upon educational outcomes. Traditional approaches highlight the importance of education for health, a perspective that has resulted in some educationists decrying health education on the basis that schools are educational and not social service institutions. The contemporary shift in paradigms, however, focuses attention on the critical role that health plays in optimising the educational outcomes of the school (Lavin et al 1992, Green and Kreuter 1990). In their recent review of health promotion attempts in American schools Lavin and colleagues (1992 p214) state "to improve academic achievement, schools and other educational institutions must devote more attention to health concerns." The health promoting school model can therefore provide a means of ensuring a comprehensive and consistent approach to health in the school community (Young and Williams 1989). Why is food and nutrition an important component of a health promoting school? The issues discussed in the above section apply particularly to the area of food and nutrition. That there is an inequity of access to healthy foods among specific groups and individuals is now recognised. This is made explicit in the following excerpt form the National Food and Nutrition Policy of the Commonwealth Department of Health, Housing and Community Services. The role of proper nutrition in the achievement of social justice has in the past been under recognised against other social and economic concerns. Proper and adequate nutrition is linked to growth, strength, educational outcomes (authors parenthesis) and health throughout life. A fundamental aim of the policy is then to increase the availability of nutritious foods, especially in remote areas, to increase the affordability of nutritious foods for economically disadvantaged people, and to increase the understanding of good nutrition and foods (authors parenthesis). p4 The importance of good nutritional health to optimise learning outcomes has also been recognised (Lavin et al 1992). These authors provide excerpts from four national working groups addressing health education. In three of these explicit reference is made to nutrition education. The National (American) Education Goals for example include in their objectives: Children will receive the nutrition and health care needed to arrive at school with healthy minds and bodies..... Further in her report regarding "the cost of neglecting our children", Hewlett (1985) writes; No matter how much money you pump into schools, no matter how well you pay the teachers, fine-tune the curricula, or enrich the programs, you do not address the critical needs of a substantial segment of students unless you also concern yourself with nutrition, health care, housing and family functioning - the factors that determine the early development of the child. (Lavin et al 1991, p218) In addition to these issues relating to social equity and optimisation of educational missions, there is compelling epidemiological evidence for the need to address food and nutrition behaviours from an early age (Department of Community Services and Health 1989). This becomes an increasingly important and potent argument when realising that traditional family modes of transmission of information and skills regarding food are being eroded and replaced, largely as a result of the dramatic increase in the size and complexity of the food supply, the increased number of families with both parents working and the powerful use of media to influence food choices (Egger 1991). As as result of arguments such as those presented above one of the National (American) Health Promotion and Disease Prevention objectives is to; Increase to 75% the proportion of the nations elementary and secondary schools that provide nutrition education from pre- school through 12th grade, preferably as part of quality school health education. (Lavin et al 1991, p218) More significant, however, is the recent call through the "Goals and Targets for Australia's Health in the Year 2000 and Beyond" for a similar goal within Australian schools. The goal outlined in relation to health education is "To provide opportunities for all students to develop health skills and knowledge to equip them for life". The associated target is "To increase the proportion of schoolchildren who complete a comprehensive health education curriculum from school entry until they finish school" (Nutbeam et al 1993). How does a school community implement the health promoting school model? The health promoting school model provides a framework for school community-based development in health. It directs thought towards specific areas. Implicit in this model is the notion that development evolves through a democratic process (Kickbusch 1992). Thus an appropriate method for directing planning, implementation and reflection is embraced in participatory action research. Participatory action research has been described as resulting from the convergence of two intellectual and practical traditions, these being 'action research' and 'participatory research' (Mc Taggart 1992). It occurs when 'academics' and 'workers' are joined by a common concern (thematic concern) and make a commitment to investigate, plan, act and observe in order to improve this practice or situation. Critical to this process is that those who will be affected by planned changes play a major role in determining and reflecting upon the success of the path of action or strategies selected (Kemmis and Mc Taggart 1988). Thus groups or individuals who have a stake in the particular issue of concern should be co-opted to play a major role in determining how it will be addressed. The health promoting school model may aid in identifying those areas that need to be considered in developing an action plan. The remainder of this paper will trace the development of health promotion programs in four Queensland schools involved in the Nutrition Education and Teenagers project (NEAT). Particular attention will be made to developmental links that were made between nutrition related initiatives and those relating to other health issues. Methods. Schools. Nutrition and health related developments in one trial NEAT project school and three schools involved in the subsequent pilot NEAT project will be outlined in this paper. Whilst impact, outcome and process evaluations were undertaken in all schools (pilot schools are still in their implementation phase) the evaluative method used for this paper will most resemble a case study approach. The trial school. The NEAT project was initiated as part of a larger community health program, HEALTH 2000, being conducted by the Nutrition Program, the University of Queensland in a large rural Queensland town. This project was funded through the National Better Health Project. The HEALTH 2000 project team received a number of requests from school teachers at the local secondary school. These requests were for assistance in developing programs to address the food habits of school students. Recognising the importance of the school in the local community and thus to a community health project, the project director initiated the NEAT project with the appointment of a project officer. Initially a needs assessment instrument was developed for students. The purpose of this instrument was to describe the eating patterns of students and the major influences on these eating patterns. A paper describing the process of development of this instrument is currently in press in the Australian Journal of Nutrition and Dietetics. A similar questionnaire was developed for parents to identify their perceptions of the importance of food for their children and the influence they exert upon their child's food intake. The results from these questionnaires were incorporated into a report that was presented to volunteer representatives from groups including teachers, administration, students, parents, canteen workers and local health agencies. Following discussion this group unamiously decided to work to address four food habits that they identified of major concern. The Health Promoting School was not suggested as a framework for this development as the investigator was at that time unaware of the existence of the model. Initially, planning was undertaken from August 1991 to December 1991 for implementation in the new school year in 1992 although some of the activities were implemented in the 1991 school year. Planning was ongoing through the main implementation period of February 1992 to June 1992 the direction of which was determined by the groups evaluation of the success of various initiatives. Thus the approach used could be considered a modified version of participatory action research, as the general thematic concern addressed by the group was to some extent mandated by the project team although it had initially resulted from requests from staff. Mechanisms were put in place to assess the efficacy of the process of planning. These included the documentation of: (i) the number of planning meetings; (ii) the attendance rates at these meetings; (iii) the number and diversity of initiatives developed; (iv) the allocation of resources to nutrition education; (v) working group members satisfaction with the process; and, (vi) the nutrition education teachers perceptions of the quality of programs developed. Process indicators (i), (ii) and (iii) were addressed through the recording of minutes and documentation of working group and sub- group meetings. Indicators (iv) to (vi) were covered through individual and focus group interviews and informal conversations with working group members and teachers of nutrition education. Impact and outcome evaluation was also conducted in the trial school. As these evaluations are not pertinent to the argument proposed in this paper they will not be discussed. The Project Schools. Following the completion of the trial project a larger pilot project was instigated in June 1992 which involved six Queensland secondary schools of various size, geographical and socio- economic backgrounds. Teachers from two of these schools had requested that their school be involved whilst the other four responded to calls for invitations of interest. A similar process of reporting results of needs assessments to groups of stakeholder representatives was undertaken in each pilot school. In all schools working groups were set up to address issues identified as priorities. The Health Promoting School model was suggested to all these groups as a framework for development. However explanation of and reference to this model was always from the perspective of food and nutrition. As this pilot project is still underway, information currently available regarding the program components undertaken by three schools will be used to support arguments based upon the trial school experience. Results The Trial School. The student food habits of concern identified by the working group, were embraced by the following (outcome) objectives. To facilitate among year eight students; (i) an increase in the intake of food containing complex carbohydrate (breads and cereals and fruits and vegetables); (ii) an increase in the variety of food consumed from the four major food groups; specifically rice, pasta, yellow vegetables, yoghurt, cheese and fish; (iii)an increase in the consumption of wholemeal and wlolegrain products; and, (iv) a reduction in the consumption of fried and other take-away food. To address these food habits the working group selected four areas for development. These were; * the health education curriculum, * the school canteen, * parental education and involvement, and * the media and community awareness. Pre to post-program impact and outcome evaluation provided promising results. However, as has previously been suggested, the focus for the argument presented in this paper lies with the results from process evaluation. Each of the process indicators identified in the methods section will be addressed individually. (i) A total of twenty planning sessions were undertaken from August 1991 to June 1992 including ten working group meetings, five curriculum sub-group meetings, two full day curriculum sub- group workshops and three canteen sub-group meetings. (ii) The overall attendance rate for these meetings was 79%. (iii) Table 1 outlines the programs and initiatives that were planned and implemented through the trial period and those areas at which the initiatives were targeted. Activities to address parental education and involvement, and the media and community awareness have been included together as "Community and Parents". (iv) In all sixty lessons in nutrition education were allocated as a result of planning. This represented a two and a half fold increase compared with the previous year. There was no change in the total number of lessons allocated to physical activity based curriculum compared to the previous year. However, there was a shift in the emphasis of the program from one based upon skill development in games and sports to one focusing upon health based physical activity. Table 1: Programs and initiatives planned and implemented for target areas through the trial period. Programs and Initiatives Planned andCurriculumCanteenCommunity ImplementationImplemented & Parents Oct 1991 * commence writing of food and nutrition * program for year 8 students * visit to tuckshop expo in Brisbane * Nov 1991 * trial of year 8 "muffin promotion" in the * * school canteen *"Yummy food ideas for the school * * canteen" a trial at Awards Night * article in local newspaper with paragraph on project * commence "canteen new food program" * - mini-pizzas * commence development of health related * fitness program for year 8 students to compliment food and nutrition program * commence development of canteen * policy Dec 1991 * recruitment drive for canteen * February 1992* curriculum implementation begins * * introduction of project at staff meeting * * "canteen new food program" - fruit salad and salad plates * March 1992* first parent workshop series including sessions on; * stress management, fitness monitoring, fun ideas with fruit and veges, reducing cancer risk, food facts and fallacies, exercise for fun and fitness. * "canteen new food program" - steamed mini spring rolls April 1992* ministerial launch of project (education * minister) with TV and newspaper coverage * "canteen new food program" - beef and vegetarian lasagne * commencement of "Homework for * Parents" project May 1992* "canteen new food program" - spaghetti bolognaise June 1992* second parent health workshop * local radio talkback regarding the project * involving student members of the working group * * * * * * * * * * (v) With the exception of one working group member who described the planning process as being "all too wishy washy", there was a high degree of participant satisfaction with the process. Typical comments were; I think the committee worked very well. We achieved a lot. I think it was a good way of approaching it, taking the school on as a whole. I can't see any other way. (vi) In addition there was an extremely high level of teacher satisfaction with the programs developed. A typical comment was; I think it's more experience based. We are not putting as much emphasis on getting information across to them. It's not "you must learn this". It's related to everyday experiences and that's why they are finding it more relevant. The Pilot Schools. School 1 is located in the hinterland of the Gold Coast and is for students from pre-school to year twelve. An enthusiastic NEAT committee formed including representatives of students, parents, teachers, canteen staff and administration. The rewrite of the year eight Home Economics curriculum was initiated as an independent undertaking. However it soon became co-ordinated with the development of the new Health Based Physical Activity curriculum. In 1994 these two subjects are to be integrated into one, optimising the complementarity of food and physical activity. Through the rewriting of the Home Economics curriculum, the textiles component was converted to a unit on kite making with community members and parents involved in the production and test flights of the kites. Whilst kite making and physical activity do not fall within the boundaries of nutrition education, these developments were supported by the project team as it was felt they would contribute to the quality of the curriculum and the social environment of the school. Workshops addressing health and nutrition have been held for staff with the emphasis being upon the importance of role models. Regular luncheons for parents which were part of the school operation prior to the NEAT project, were used as a forum for students to address their parents on a variety of health topics. School 2 is situated in a large semi-rural town approximately two hours drive from Brisbane. Initial work at this school included modification of both the Home Economics and Health and Physical Education curricula with emphasis upon the practical food preparation components and the strengthening of links between the subject areas. Review of the school canteen indicated that it was a well run establishment with many healthy options available to students. However, successful trials to introduce additional healthy foods were undertaken. In particular, freely available healthy foods, identified by the needs assessment as being rarely eaten by most students were successfully introduced in the canteen. The development of school canteen policy is ongoing and has largely concentrated on documenting the mode of operation. The committee at this school felt that teacher health was critical to the social environment of the school, so links were established with the project team of the Worksite Health Promotion Program from Queensland Health. As a result, initial needs assessment through focus interviews with staff has been undertaken with results reported back to staff. A staff welfare committee, already in existence at the school, has taken on the responsibility of developing recommendations from the needs assessment. As a number of projects running simultaneously in the school fall within the rubric of health promoting schools, an overall map of activity in this area is being developed incorporating both new and already existing initiatives. Approximately sixty students attended School 3 which is a secondary department in a small country town two hours drive north of Brisbane. Again attempts to rewrite the Home Economics curriculum resulted in a similar undertaking for Health and Physical Education. The emphasis in these programs was upon short term incentives for students and practical experiences. Students studied and prepared healthy foods that were freely available to them but they rarely ate. They created a restraunt and invited their parents for lunch serving these foods with descriptions and explanations of them. These activities have been written into the Home Economics curriculum. The project team in the school was successful in gaining a several thousand dollar grant for the purchase of gym equipment to develop a circuit training area. This area will provide the laboratory for study in health based physical activity but will also be made available to the local community for use. The team also successfully lobbied for funds to replace fly screens and update refrigeration facilities in the food preparation area. In addition a regular food related feature has been included in the school newsletter with local media coverage undertaken. Workshops focusing on healthy lunch ideas for the school canteen have been conducted. Alterations to school lunchtime rules to promote access to healthy foods is currently being mooted. Discussion. A number of indicators for the evaluation of the process of planning at the trial school have been outlined. Results indicate there was a high degree of activity among working group members with initiatives planned and implemented addressing all components of the health promoting school even though it was not used as a framework for development. In addition, with one exception there was a strong feeling of satisfaction from both working group participants, regarding the process of planning, and teachers regarding the food and nutrition work units. A dramatic increase in the allocation of resource to food and nutrition education and health related physical activity was also achieved. Scrutiny of the activities undertaken at the trial school (Table 1) shows that two initiatives were not specifically related to food and nutrition. Firstly, the development of the physical activity based program to compliment the nutrition related curriculum occurred subsequent to and as a direct result of the latter. A similar occurrence was documented in the three pilot schools with the working group in one school also extending this development to include kite making. As funding for the NEAT project was explicitly for the area of food and nutrition, the extension of curriculum development to include exercise and other related components was not promoted by the investigator, although these initiatives were supported once selected by the working groups. Secondly the parent workshops that were conducted at the trial school addressed a variety of health related issues, although two related specifically to food. Again a similar pattern emerged in the pilot schools. Improvement of staff health and staff and community physical activity were selected as areas for development in two pilot schools. The documentation of explicit links to other areas of activity within the school community is also being undertaken in one school. Again whilst not being encouraged by the project officer such initiatives were supported once there was a strong indication by the working group that this was the direction that they wished to pursue. There has been a strong belief that whilst the case study approach provides a useful methodology for the study of human affairs, it does not provide a suitable platform for generalisations about such events (Stake 1978). However, it has been suggested that the search for similarities and variations within particular situations may result in 'naturalistic' generalisations that are both intuitive and empirical (Stake 1978). If this tenet is acceptable then it seems possible to draw such a generalisation from the cases briefly discussed above. This is in relation to a particularly useful approach for the initiation of a health promoting school project within a school community. One characteristic of the Health Promoting Schools movement has been described as a shift in the point of entry for school-based health; from one embracing health issues towards one that focuses upon a health settings (Kickbusch 1992). Nevertheless, the results from the NEAT project outlined above indicate that food and nutrition working groups from four different schools have consistently attempted to develop explicit links with other health areas when supported but not encouraged in this endeavour. 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