Unit 1

Introduction to the Concept of Health Promoting Schools

Overview
The purpose of this unit is to introduce the key concept of Health Promoting Schools (HPS). This course focuses on the concept of Health Promoting Schools and advocates that not only teaching and learning, but the holistic development of individuals will flourish in such an environment. This unit presents three ideas: First, it provides social and historical information about the Caribbean context from which the idea of health promoting schools has emerged. The main intention here is to show that modern education systems in the Caribbean have significantly different aims from the ones that initiated primary education, and that there are now vastly different expectations of what these systems should, and must, produce for their stakeholders. Second, it argues that health promoting schools are concerned with health broadly defined, not merely physical or environmental health. In other words, healthy schools must cater to the needs of their many clients and stakeholders (students, administrators, teachers and parents) by going beyond providing clean surroundings and attending to matters of hygiene. Third, it explains that the notion of Health Promoting Schools gained prominence with the rise of health and family life education, which replaced family life education in the Caribbean. This unit consists of the following three sessions. Session 1: The socio-historical development of education. Session 2: What is a Health Promoting School? Session 3: The evolution of health and family life education in the Caribbean

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Unit 1 Learning Objectives

By the end of this unit, you should be able to: 1. Describe the socio-historical forces that have impacted upon Caribbean education systems. 2. Account for the prominence that the concept of Health Promoting Schools enjoys in Caribbean educational environments. 3. Discuss the characteristics of a Health Promoting School. 4. Discuss the aims of health and family life education.

Key Concepts
Education Health Promoting School Health and family life education

Key Collaborating Agencies

World Health Organization (WHO) Pan-American Health Organization (PAHO) Caribbean Community (CARICOM)

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Session 1

The Socio-historical Development of Education

Introduction
One of the principal way in which skills, expectations and roles, as well as the collective wisdom and understanding of society is passed on from one generation to the next is through formal education. Formal education, in particular the setting in which it occurs, is regarded as the major agent of socialization in contemporary society. In this session, we will examine the evolution of education, its structures and process, and the social factors that have influenced systems of education over the years.

Objectives
By the end of this session, you should be able to: discuss the origins and development of education in the Caribbean; identify factors that have influenced the development of education in the region.

The Socio-Historical Context of Education in the Caribbean

Education encompasses all those activities that a society engages in, in order to inculcate its new members with its norms and values. Education is concerned with the formal transmission of knowledge and implied in the term is an understanding that what is being transmitted is something that is worthwhile and of value. There has always been a close relationship between education and society, and changes in the expectations of society have been reflected in changes in education over the years. Most of the countries in the Caribbean share a common history of slavery and indentureship and the progression from colonialism to independence. The economy of the pre-emancipation colonial society was based on slavery and sugar, or other plantation crops, and ones position as an individual in that society was determined by ones socioeconomic standing, be it as planter, slave, free black or coloured. Education at that time was the business of the church and private individuals, and not the government. What little provision for education there was, served the whites. Free blacks and coloureds were excluded from schools. Slaves were only exposed to religious teaching in the form of indoctrination by the clergy and missionaries. Post-emancipation colonial society was shaped liked a three-tiered colour and class pyramid, with different nationalities, cultures, religions and languages cutting across
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the colour strata. It became a cosmopolitan, heterogeneous society, including diverse immigrants, with different religious denominations delivering religious and elementary education. At the time of emancipation, and immediately afterwards, there were two main sources of funding providing assistance to education in the Caribbean. The Negro Education Grant was provided for in the British Emancipation Act of 1833. For ten years these funds were available to missionaries with the primary aim of delivering religious education. The Mico Trust also benefited from these funds. This Trust, which had originally been set up to free British sailors, was used for the education of ex-slaves and for teacher training (King, 1996). These funds subsidized the building of new schools and ensured the payment of teachers, for religious and moral education. However, these funds were administered from metropolitan bases. Caribbean governments had no control over how these funds were spent and there was no official surveillance over the quality or qualification of teachers. Primary education tended to be catechism taught by unsupervised, poorly paid teachers, who themselves had little education. Schools were often sited to be in competition with those of other denominations rather than for any appreciation of the needs of the population. Little was done during this period to provide education for children of former slaves; education was not seen as a universal right and there were also misgivings about the consequences of educating the lower ranks of society. One of the main issues was the place of religion in an educational system in which the state began to admit a responsibility. Some Caribbean governments eventually tried to take control away from the churches. In Trinidad, where the Roman Catholic church was predominant, Governor Lord Harris, in an attempt to integrate the heterogeneous cosmopolitan society, introduced a secular system of education in 1851. Thirty ward schools, two model schools and a school to train teachers were established. Harris believed that education would improve economic and social conditions for a country that had a large number of unskilled and manual labourers. Religious instruction was not to be imparted in the schools and school expenses were to be met by local boards. The entire management and control of the schools, the appointment and dismissal of teachers, the determination of the cause of instruction and of the books to be employed were to be vested in a Board of Education. This secular system of education did not get off to a strong start, mainly because the wardens, who were planters, were not eager to develop schools and because insufficient revenue was provided for education. The schools failed to cater for a diverse population and there were language barriers between teachers and students. In addition, the influential Keenan Report (1869) criticized the ward schools and the state of public education in Trinidad and recommended the dual system of education, with denominational and state primary schools. Eventually a system that included both government schools and denominational schools, as well as other private schools, became accepted throughout the region, and continues today. In Trinidad, for example, the dual system of education, with two competitive types of elementary school financed by government, was implemented in 1870 and over the next twenty years government schools were located in areas where
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there were no church schools. In 1901 school fees were abolished allowing for greater inclusiveness (Campbell, 1992). Secondary schools were also established in the second half of the nineteenth century, although entry requirements and fees initially restricted their intake to the wealthier classes. King (1996) states that
Secondary schools in the Caribbean were grammar schools based on the English model that offered the classical languages, modern languages, mathematics and in some cases, natural sciences. They were intended to prepare boys for entry to the learned professions, or at least for other white collar occupations. Girls were prepared to be the wives and mothers of professional men.

From the early 1900s there was an expansion in secondary school places and schools. These increasing educational opportunities saw the emergence of Caribbean intellectuals who headed full-fledged political parties in the mid-1950s. Citizens were also becoming more aware of their identity and the pressing need to seek social, political and economic improvements. Here, as elsewhere, education has become increasingly important as certificates and diplomas are more and more the means of entry to the better paid, more secure higher status jobs and upward social mobility. It can be argued that emphasis in education seems to have shifted, since schools which once educated the individual in the norms and values of society now tend to focus on their intellectual and academic development. Although there has been a welcome expansion of education opportunities, there have, on the other hand, been factors that hindered some of the anticipated social and economic benefits. In order to deal with these issues, Caribbean governments are reviewing their national policy frameworks and programmes to deal with the current deficiencies and the future challenges in their education systems. One of the strategies being used to address the challenges of a rapidly changing society is that of health promotion, using Health Promoting Schools in the holistic ways that will be the focus of this course. ACTIVITY 1.1
Consider how approaches to education have changed over the last two centuries in the Caribbean. List at least five ways in which you think people have benefited from expansions in educational opportunities in your own country. Indicate whether, in your opinion, all sectors of society benefited to the same extent.

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Reading 1.1
King, R. 1996. Education in the British Caribbean: the Legacy of the 19th Century. http://www.educoea.org/portal/bdigital/contenido/laeduca/laeduca_121/articulo5/ index.aspx?culture=en&navid=221. Accessed July 4, 2007. This article examines the historical development of education in the Caribbean and some of the factors that have influenced approaches to education.

Summary
This session reviewed developments in education since emancipation, relating these changes to changes in Caribbean societys expectations.

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Session 2

What is a Health Promoting School?

Introduction
In this session we will describe the Health Promoting School model, which, with its principles of holistic health promotion, and emphasise on health and family life education, is the core theme of this course.

Objectives
By the end of this session, you should be able to: identify and discuss the principles of a Health Promoting School; describe the components of the Health Promoting School model; discuss the benefits of a Health Promoting School.

Health and Health Promotion

Since the World Health Organization adopted the following definition in its constitution, health has become more widely recognized as,
a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. (WHO, 1946)

Health promotion is recognized in the Ottawa Charter (WHO, 1986) as being the process of enabling people to increase control over, and to improve, their health. The charter goes on to say that
. . . to reach a state of complete physical, mental and social well being, an individual, or group, must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with their environment.

The Health Promoting School Model

Health Promoting Schools may vary somewhat between different physical and cultural environments, but they all share the common purpose of health promotion, and use recognized theories and tools to achieve that purpose.
Health Promoting Schools are, in essence, a health promotion strategy in the school setting and represent the application, to the specific setting of the educational communities, of the theories, scientific bases, models and tools on which health promotion is based(Ippolito-Shepherd & Castellanos, 2003, p. 44). 21

The Health Promoting School initiative has its genesis in the first international conference on Health Promotion in Ottawa in 1986. At that conference, a Charter was presented for action to achieve health for all by the year 2000 and beyond. The conference was primarily a response to growing expectations for a new public health movement around the world. Discussions focused on the needs in industrialized countries, but also took into account similar concerns in all other regions. It built on the progress made through the declaration on Primary Health Care, the World Health Organizations Targets for Health for All document, and the debate at the World Health Assembly on intersectoral action for health. The Health Promotion School concept originated in Europe following this conference, and is founded on five principles of the Ottawa Charter on health promotion: Build healthy public policy. Health promotion puts health on the agenda of policymakers in all sectors and at all levels directing them to be aware of the health consequences of their decisions, and to accept their responsibilities for health, e.g. legislation, fiscal measures, taxation and organizational change. Create supportive environments. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. Strengthen community action. Health promotion draws on existing human and material resources in the community for setting priorities, making decisions, planning strategies and implementing them to achieve better health. Develop personal skills. Health promotion provides education for enhancing life skills. This education is facilitated in school, home, work and community settings. Reorient health services. The responsibility for health promotion in health. services is shared among individuals and community groups, as well as health professionals, health service institutions and governments.

The Nature of a Health Promoting School

As we explained above, health is multidimensional, and health promotion is the process of enabling people to increase control over, and to improve their health. A Health Promoting School is a school that embraces these definitions and, as described by WHO (1986) . . . is constantly strengthening its capacity as a healthy setting for living, learning and working. To achieve these aims, a Health Promoting School has the following attributes: A Health Promoting School displays in everything it does and says, support for, and commitment to, enhancing the emotional, social, physical and moral well-being of all members of their school community. A Health Promoting School promotes a broad view of health and the role of the school. A Health Promoting School is based upon a social model of health which emphasizes the entire organization of the school, as well as the individual, where all members

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of the school community work together to provide students with integrated and positive experiences and structures which promote and protect their health. (WHO 1986)

Features of a Health Promoting School

The Health Promoting School has many aims (Box 1.1), which fall under three main areas of focus: health education, the environment and school partnerships and services. 1. Health Education. The aspect of a School Health programme that consists of planned learning experiences based on sound theories that provide individuals, grouops, and commun ities the opportunity to acquire information and the skills needed to make quality health decisions (Joint Terminology Committee, 2002, p. 5). Health education focuses on teaching and learning with emphasis on key school community issues involving nutrition, physical education, the environment, mental health and related life skills. Teaching and learning methods are participatory so as to ensure that the learner constructs his or her learning. 2. The environment consists of two aspects the physical environment and the psychosocial environment. In a Health Promoting School, the psycho-social environment, which impacts on ones psychological and social well being, has an overall positive climate which is conducive to learning and a sense of well-being. It is a combination of the quality of the relationships among staff, among students, and between staff and students. It is often strongly influenced by relationships between parents and the school, which in turn is set within the context of the wider community. It is also influenced by senior staff from within the school and by health and education personnel who visit the school, all of whom provide role models for students and staff by the attitudes and values they display in the social environment. Supportive school policies and the culture of the school are also part of that positive environment. The physical environment on the other hand, consists of adequate facilities and infrastructure to ensure that individuals are in a secured and comfortable setting where their health is not jeopardized. Some examples of the physical environment are the availability of clean water, well ventilated classrooms, adequate number of chairs and tables, well kept playground, etc. 3. School partnership and services takes into consideration school community consultation, negotiation and involvement. This is facilitated by the formation of alliances between the school and government ministries such as those responsible for health and education, and social affairs, as well as non-government organizations and other agencies that support and promote health. Parents are also closely consulted and are given the opportunity to become actively involved in the schools health promoting activities.

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Reading 1.2
Ippolito-Shepherd, J. and L.M. Castellanos. 2003. Current School Health Programmes in Latin America and the Caribbean: Overview. (Section 2.1) In Health Promoting Schools. Strengthening of the Regional Initiative. Strategies and Lines of Actions 2003 2012. Washington D.C.: Pan-American Health Organization (PAHO), pp.912. Retrieved March 18, 2007 from http://www.paho.org/English/AD/SDE/HS/HPS_ planActionNo4.pdf This reading describes the transition of thoughts on health education from thinking of schools as passive receptors to a situation in which all stakeholders in the educational community are active participants. Focusing on Latin America and the Caribbean, the authors provide examples of Health Promoting School initiatives.
Box 1.1 What is Health Promoting School? A health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning and working. A Health Promoting School: Fosters health and learning with all the measures at its disposal Engages health and education officials, teachers, teachers unions, students, parents, health providers and community leaders in effort to make the school a healthy place. Strives to provide a healthy environment, school health education, and school health programmes for staff, nutrition and food safety programmes, opportunities for physical education and recreation, and programmes for counselling, social support and mental health promotion. Implements policies and practices that respect an individuals well being and dignity, provide multiple opportunities for success, and knowledge good efforts and intentions as well as personal achievements. Strives to improve the health of school personnel, families and community members as well as pupils; and works with community leaders to help them understand how the community contributes to, or undermines, health and education.

Health promoting schools focus on: Caring for oneself and others Making healthy decisions and taking control over lifes circumstances Creating conditions that are conductive to health (through policies, services, physical/ social conditions) Building capacities for peace, shelter, education, food, income, a stable ecosystem, equity, social justice, sustainable development Preventing leading causes of death, disease and disability: helminths, tobacco use, HIV/AIDS/STDs, sedentary lifestyle, drugs and alcohol, violence and injuries, unhealthy nutrition. Influencing health-related behaviours: knowledge, beliefs, skills, attitudes, values, support.

Source: WHO http://www.who.int/school_youth_health/gshi/hps/en/index.html

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ACTIVITY 1.2 A health promoting school requires collaboration between school, community and home. Are these relationships strong in your own school? How do you think they could be strengthened?

Summary
The principles of health promotion and the nature of a Health Promoting School were described in this session before discussing the three main features of the Health Promoting School.

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Session 3

The Evolution of Health and Family Life Education in the Caribbean

Introduction
In this session we will review how, with the increasing concern for human development and the quality of life, health education has shifted from emphasizing the physical health of the individual to the more comprehensive or holistic approach that is embraced in Health Promoting Schools.

Objectives
By the end of this session, you should be able to: summarize the developments related to the evolution of health education in the Caribbean; compare the aims of health education, family life education and family life and education programmes.

From Health Education to Health and Family Life Education in the Health Promoting School: the Caribbean Experience
The CARICOM Multi-Agency Health and Family Life Education project promotes health and family life education through health promoting schools. Having given the CARICOM Secretariat and The University of the West Indies a mandate to develop the strategy for a comprehensive approach to health and family life education , the Caribbean Ministers of Education and Health, in 1996, accepted and endorsed the Health and Family Life Education Strategy Framework, which is the basis of this project. Health and family life education is an integral part of the projects conceptual framework. This replaces the previous family life education curriculum and reflects the principles of a Health Promoting School that were described in the last session, by going beyond considering health only in relation to illness or injury. As we will see, health education and family life education were antecedents to health and family life education, which evolved as a strategy to address issues across the spectrum of physical, mental and spiritual strength and health.

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Education and health are linked in several ways (Box 1.2) and an inextricable link between education and health has existed for many decades, but, generally, in the Caribbean the focus of health education used to be on the physical well-being of the individual as opposed to the holistic approach. Box 1.2: What are the Links BetWeen heaLth and education?
Good Health Supports Successful Learning and Successful Learning Support Health A childs ability to attend school is affected by his/her health. Health and psycho-social problems, such as diseases among children and their families; over- or under-nutrition, poor hygenic and sanitary conditions in the school; fear of violence or abuse at home, en route to, or in school; and poverty; can impact on enrolment, reduce attendence, and negatively impact on cognitive development and learning outcomes, thus reducing the value of investment in education. Education and childrens health are linked in various ways: The culture, organization, and management of the school; the quality of its physical and social environment; it curricula, teaching and learning methods; and the manner in which students progress is assessed, have direct effects on self-esteem and educational achievement, and therefore on the health of its students and staff. (WHO, 1997, p.2) School nutrition programmes, diagnostic screening for physical, emotional and learning disabilities, and intervention strategies that address identified deficits, improve physical and emotional well being of students, and contribute to higher school enrolment, lower rates of absenteeism and school dropout, and improved classroom performance. Violence, unintended injuries, suicidal tendencies, and related lifestyle behaviours, such as the use of alcohol and other drugs, interfere with the learning process. Children exposed to violence may become highly aggressive, use psychoacitve substances, or show other dysfunctional ways of dealing with anxiety. This behaviour, in turn, may reduce attendence at school, impair concentration, and detrimentally affect cognitive development. (UNESCO,
2000/2001).

Early sexual initiation, sexual behaviours that result in HIV infection and other sexually transmitted diseases, and early pregnancies, can affect students participation in education. The health benefits of education are especially pronounced with regard to girls. Evidence for the benefit of education to girls themselves, their future children, and their society is overwhelming. The single most important determinant of a childs health is its mothers level of education. (WHO, 1997)

Source: Rampersad, (n.d.)

Health education in schools was taught as separate subjects, such as Health Science, Health Education, Sex Education, or Family Life Education. With the increasing concern for human development and the quality of life, health education shifted from emphasizing the physical to a more comprehensive or holistic approach. In the 1960s there was an increased awareness, in the Caribbean as a whole, of risk factors associated with children and youth, such as problems related to their sexual and reproductive health, including teenage pregnancy and sexual abuse; low school enrollment and attendance; violent behaviour and poor dietary habits. It became clear that the goal of health education programmes should be to address these social issues by educating individuals for life and to reduce family problems. As a result, Family Life Education was introduced in the Caribbean.
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Family life education represented a move towards a more holistic approach. It has been defined as:
A dynamic process in which all persons are involved it is concerned with preparing persons for life it is concerned with helping persons to live purposeful and creative lives. As such it is not the province of any one group, or agency or discipline. It requires the concerted and systematic efforts of the home, the school, the church and community agencies
(Pan American Health Organization/World Health Organization, (1978, p. 13)

Alleynes (1982) recommendations for curriculum content for family life education for Junior Secondary Schools in the Caribbean illustrate the focus of health education at that time and an increasing concern about social issues. His proposed curriculum included the following areas: Communication Personal Development Social Development Adolescence Human Reproduction Contraception Reproduction and Family Formation Family and Community Relationships Health Coping with Stress Nutritional Health Consumer Education Career Guidance

The family life curriculum throughout the region covered far more social concerns than health education had, but, in general, continued to approach these on a subject basis. Despite the rationale for its development, evaluation of family life education programmes revealed serious limitations, which included: A number of overlapping topics Little impact on risk-taking bevaious Insufficient coordination among agencies involved in family life related activities Lack of supportive policy Lack of teacher training Lack of supporting materials.

Family life education featured in the regions education systems for about twenty years, but, eventually, it was recognized that it was making insufficient impact in the face of increasing social and health problems in the region. After several initiatives to strengthen family life education programmes, it was eventually replaced by the current emphasis on health and family life education, which has been adopted regionally through the CARICOM Multi-Agency Health and Family Life Education project. Some of the differences in approach to health education prior to the Health and Family Life Education/Health Promoting School approach and now are summarized in Table 1.1
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Table 1.1 Comparison of a Traditional Health Instruction Program with a Health Education Program in a Health-Promoting School
Traditional Health Progam Emphasizes knowledge and attitude changes that would lead to behaviour change. Views school health program in terms of instruction, services, and environment. Emergent Health Program Applies multiple theories and models to promote health-enhancing behaviours. Promotes expanded program: instruction, environment, food services, physical education, guidance and counselling, work site health promotion, and integration of school and community. Replaces health instruction model with health promotion model. Identifies and develops comprehensive curriculum. Coordinates health promotion activities throughout school and community, including infusion of health content areas across curriculum. Encourages active student participation, using methods that match teaching techniques with instructional goals. Recognizes commonality of skills needed to address various health issues and includes common skills in curriculum. Takes wider view of school, including the relationship with community; effort to develop a caring school community with high expectations for all students. Considers family involvement in the lessons and in the development of the total program as central to the health-promoting school.

Makes health instruction the focal point. Pays little attention to coordination or comprehensiveness. Curriculums spotty; offerings uneven. Considers health education in limited terms.

Uses didactic, teacher-led instruction and acquisition of facts. Responds to crises one by one. Considers adoption of health-promoting behaviors a result of instruction. Does not routinely involve parents in school health program.

Source: Adapted from Haber and Blaber (1995)

Health and family life education not only refined the concept of family life education by fully embraced the objectives of capturing a multidimensional approach to health, it also became the foundation for re-evaluating the regions approach to schooling. As defined in the CARICOM framework (CARICOM, 2000):
Health and family life education is a planned, comprehensive, life skills-based and child-centred programme of learning which will promote an understanding of the principles which underlie social and personal well-being and will foster the development of the competencies and attitudes that make for a healthy social and family life.

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In other words, health and family life education, and health promotion through Health Promoting Schools, are a societal intervention. Family, school and community work together to promote health by providing learning experiences that develop positive values. The CARICOM project differs from previous subject-based programmes, because it uses a thematic approach to the curriculum. Similar health topics are clustered into four core areas of learning. These themes, and their related areas of concern, are: Human sexuality: teenage pregnancy; STDs/AIDs; self-esteem; self-awareness; incest/rape Appropriate eating and fitness: undernourishment; obesity; anaemia; physical fitness Social/emotional issues: interpersonal relationships; communication; drug abuse; anger management; stress management Managing the environment: control of pests and vectors; prevention of infectious diseases; control and reduction of environmental changes; marine pollution.

The aim of this thematic approach is to provide young people with improved selfesteem and resiliency. One of the key features of Health and family life education, which will be discussed in more detail later in this course, is the teaching of core life skills. Core life skills strengthen an individuals abilities in decision-making, communication and in building relationships. By building those skills, the Health Promoting School is expected to develop well balanced and well adjusted individuals. Such individuals would be: Self confident and self reliant, with a commitment to realizing their full potential; and concerned and informed about responsible sexual behaviour. Informed on the use of health services, and able to make healthy lifestyle choices. Able to use appropriate conflict resolution, as well as stress and anger management. Committed to environmental protection and the health of their communities.

Optional Readings
The following readings are available at your UWIDEC site. UNICEF. 1995. A Strategy for Strengthening Health and Family Life Education in CARICOM Member States. Paper presented to CARICOM Standing Committee of Ministers of Education, September, 1995, pp. 3345. Haber, D. and Blaber, C. 1995. Health Education Foundation for Learning. In A.A. Glatterhorn (ed.) Content of the Curriculum (2nd edn.) Alexandra, PA: Association for Supervision and Curriculum Development.

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Summary
The development of health education in the Caribbean, leading to the current focus on health and family life education and the Health Promoting School, has been reviewed. The elements and objectives of the Caribbean Health and Family Life Education Programme were also discussed here.

Unit Reflection and Discussion

Having read the information provided in the unit, how do you envision a Health Promoting School? To help us identify what is, or is not, health promoting about our schools, consider any school that you know, or have known, as either a pupil or a teacher. What features of this school promote good health, 1. physically 2. socially 3. emotionally? Were there any aspects of school life that did not promote good health?

Discuss these questions with your tutor and colleagues in the course site discussion forum for this week.

Wrap Up
This unit presented essential background information necessary for understanding the context in which the ideal of Health Promoting Schools operates. What has been revealed in an unequivocal manner is that Caribbean schools have subscribed to a model of schooling that, if adopted whole-heartedly, will change the nature of interpersonal relations in schools and alter stakeholder expectations of what educators and the education system should do in the business of schooling. As we move on to the next unit, you should keep to the forefront of your attention the tension between the historical role of education and the new health promoting role envisaged for it. Based on these understandings, we will look at the ways in which traditional approaches to schooling and pedagogy have operated. Specifically, we focus on the ways that traditional approaches to schooling can be restrictive in ways that do not reflect the principles of health promotion.

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