MHP Guidance Documents

School Health

Acknowledgements

The co-chairs would like to acknowledge the contributions of the Working Group members and the writer, Yvette Laforêt-Fliesser, who were so generous with their knowledge and expertise in school health promotion. Special acknowledgement is also due to Judith Hoy, who offered her expertise as a school board administrator. We are also grateful for the support of the Cancer Care Ontario staff: Frederick Appah, Tatyana Krimus and John Garcia and for the guidance and direction of the Health Promotion Guidance Documents Steering Committee.

Section 1. Introduction

Under Section 7 of the Health Protection and Promotion Act (HPPA), the Minister of Health and Long-Term Care published the Ontario Public Health Standards (OPHS) as guidelines for the provision of mandatory health programs and services by the Minister of Health and Long-Term Care. Ontario’s 36 boards of health are responsible for implementing the program standards including any protocols that are incorporated within a standard. Order in Council (OIC) has assigned responsibility to the Ministry of Health Promotion (MHP) for four of these standards: (a) Reproductive Health; (b) Child Health; (c) Prevention of Injury and Substance Misuse; and (d) Chronic Disease Prevention. The Ministry of Children and Youth Services has an OIC pertaining to responsibility for the administration of the Healthy Babies Healthy Children components of the Family Health Standards. The OPHS are based on four principles: need, impact, capacity and partnership/collaboration. One Foundational Standard focuses on four specifi c areas: (a) population health assessment; (b) surveillance; (c) research and knowledge exchange; and (d) program evaluation.

a) Development of MHPs Guidance Documents

The MHP has worked collaboratively with local public health experts to draft a series of Guidance Documents. These Guidance Documents will assist the staff of boards of health to identify issues and approaches for local consideration and implementation of the standards. While the OPHS and associated protocols published by the Minister under Section 7 of the HPPA are legally binding, Guidance Documents that are not incorporated by reference to the OPHS are not enforceable by statute. These Guidance Documents are intended to be resources to assist professional staff employed by local boards of health as they plan and execute their responsibilities under the HPPA and the OPHS. In developing the Guidance Documents, consultation took place with staff of the Ministries of Health and Long-Term Care, Children and Youth Services, and Transportation and Education. The MHP has created a number of Guidance Documents to support the implementation of the four program standards for which it is responsible, e.g.:

Child Health
Child Health Program Oral Health
Comprehensive Tobacco Control
Healthy Eating, Physical Activity and Healthy Weights
Nutritious Food Basket
Prevention of Injury
Prevention of Substance Misuse
Reproductive Health
School Health

This particular Guidance Document provides specifi c advice about the OPHS Requirements related to SCHOOL HEALTH. This guidance document varies somewhat from other guidance documents as a settings-based document that describes a comprehensive health promotion approach for schools that is relevant for many standards and requirements. Please refer to the Guidance Documents listed above for additional information, including schoolbased interventions specific to the requirement.

b) Content Overview

Section 2 of this Guidance Document provides background information relevant to school health, including the signifi cance and burden of this specifi c public health issue, a brief overview about provincial policy direction and strategies, as well as supporting evidence and rationale.

Section 3 provides evidence to support a comprehensive health promotion approach for each program in the OPHS (2008) that includes a requirement for public health units to work with school boards and/or schools, including evidence-based practices, innovations and priorities within the context of this partnership work. It includes general and specifi c considerations in using a comprehensive health promotion approach with educational settings, and also addresses mental health and determinants of health considerations in the public health approach to this setting.

Section 4 identifies and examines areas of integration with other program standard requirements. This includes the identifi cation of opportunities for multi-level partnerships (i.e. provincial, municipal/boards of health, community agencies and others). Identifi cation of collaborative opportunities with other provincial strategies and programs are also highlighted.

Finally, Section 5 identifies key tools and resources that may assist staff of local boards of health to implement the program standards related to school settings and to evaluate their interventions.

Section 6 is the conclusion.

c) Intended Audience and Purpose

This Guidance Document is intended to be a tool that identifies key concepts and practical resources that public health staff may use in health promotion planning with schools and school boards. It provides advice and guidance to both managers and front-line staff in supporting a comprehensive health promotion approach to fulfi ll the OPHS Requirements in educational settings (i.e., of Chronic Disease Prevention, Injury Prevention and Substance Misuse, Reproductive Health, Child Health, Sexual Health, Vaccine Preventable Diseases, Sexually Transmitted Infections, Blood-Borne Infections (including HIV) and Infectious Diseases Prevention and Control).

Note: In the event of any confl ict between the Guidance Document and the Ontario Public Health Standards (2008), the Ontario Public Health Standards will prevail.

Section 2. Background

a) Public Health Burden

Children and youth are recognized as a priority population in Ontario. The Ontario Government is committed to a smarter and a healthier Ontario. Indeed, the future economic health of this province depends on the academic success and optimal health and well-being of its children and youth. (1) Childhood is known to be a time when health practices and behaviours are learned, and adolescence is a period when both positive health behaviours (such as eating practices and physical activity) and at-risk behaviours such as alcohol and drug-use are adopted. (2–3)

The 2006 Health Behaviour in School-aged Children [HBSC] study (4) identiﬁed a number of health concerns for Canadian children and youth:

Almost half of Canadian children in Grades 6 to 10 are physically inactive.
About 26% of boys and 17% of girls are overweight or obese.
Over half of Grade 9 and 10 students report trying alcohol by age 15.
About one in ﬁve students miss one or more days of school in a year due to injury.
Just fewer than 40% of students report being victims of bullying.
By Grade 10, girls are experiencing poorer emotional health than boys.

The Mental Health Commission of Canada (5) recently reported that child/youth suicide is the leading cause of death among Canadian adolescents, and that one in four children have at least one mental health problem. About 14% of children aged 4 to 17 experience clinically important mental health disorders and fewer than 25% of these children receive treatment. (6) Another federal report, Healthy Weights for Healthy Kids, (7) warned that if current health trends continue, today’s children will experience a shorter lifespan than their parents. In 2000/2001, obesity cost Canada’s health care system an estimated $4.3 billion: $1.6 billion in direct costs, such as hospital care, drugs and physician services, and $2.7 billion in indirect costs, such as lost earnings due to illnesses and premature deaths associated with obesity. (8) Other risk factors that appear in childhood also contribute to the potential economic burden and underscore the importance of effective and comprehensive health promotion approaches.

b) Schools as Important Settings for Comprehensive Health Promotion

Schools are important settings for comprehensive health promotion. Next to the family, the school exerts the most inﬂuence on the lives of children and youth. Canada’s schools are the workplace for 20% of our population, including 5 million students and over 400,000 employees. Another 30% of the population (parents) has a direct stake in schools through their children. (9)

Health promotion within a “setting” is underpinned by a number of principles and perspectives drawn from the World Health Organization’s (WHO) Health for All Strategy and the Ottawa Charter for Health Promotion. These reports shifted the focus to the creation of supportive environments by emphasizing the holistic and multifaceted approach embodied by the “Healthy Settings Movement” that integrates health promotion and sustainable development. (10) In 1997, the Jakarta Declaration emphasized the value of settings for implementing comprehensive strategies and providing an infrastructure for health promotion. According to the World Health Organization, settings, such as schools, universities, work sites, hospitals, villages and cities, are efﬁcient “places and contexts” to promote health, to reach individuals, to gain access to services and to synergistically bring together interactions throughout the wider community. (11) Therefore, a settings approach promotes a healthy working and living environment, integrates health promotion in the daily activities of the setting and works collaboratively with the community. (12)

While many factors inﬂuence the physical, social and emotional well-being of children and youth, research increasingly identiﬁes the school setting as having a positive impact on most of the health behaviours and outcomes of this population. (4) Schools can play a key role in supporting students’ health and, by extension, the health of their families and communities. According to the WHO (13), “an effective school health program can be one of the most cost-effective investments a nation can make to simultaneously improve education and health.”

There is growing evidence from around the world that health and education are inextricably linked to each other and to other issues, such as poverty and income level. (14) Healthy young people are better learners and are more likely to complete their education. Research also indicates that those with a good education have a better health status. Education is a key determinant of health that affects other determinants such as employment, income, housing, health literacy and social status. Studies have identiﬁed the links between speciﬁc health behaviours and education outcomes, student attitudes and behaviours. (15) For example, the 2006 HBSC Survey (4) found that students with higher academic achievement and a positive attitude towards school are more likely to engage in healthy behaviours and have better emotional health and well-being. In addition, they have a greatly decreased likelihood of consuming sweets and soft drinks, engaging in risky behaviours such as bullying and sustaining a serious injury. An earlier study suggested that school experiences affect health behaviours including, substance use, injury, physical activity participation, nutrition, dental hygiene and mental and physical health. (16)

Over the past two decades, research has shown the effectiveness of comprehensive, whole-school approaches in addressing speciﬁc health issues. A 2006 meta-analysis of school-based health promotion reported that interventions that promote healthy eating, physical activity and mental health were most effective, particularly if the approach included the “involvement of the whole school, changes to the school psychosocial environment, personal skill development, involvement of parents and wider community and implementation over a long period of time.” (17, p.16) In Canada, an evaluation of a health-promoting school initiative that focused on obesity prevention and reduction in Annapolis Valley schools revealed that students in project schools made healthy food and physical activity choices more often, when compared to other students in Nova Scotia. These choices are having a positive impact on their health. (18)

More recently, some research studies and evaluations of comprehensive school health promotion initiatives are beginning to report a link between the successful implementation of this approach and academic achievement. In an American retrospective examination of the relationship between the implementation of coordinated school health programs and school-level academic indicators, Rosas, Case and Tholstrup (19) found that schools with high levels of implementation had better school-level performance and progress ratings. Another U.S. study (20) reported a positive relationship between multi-component school health programs and students’ academic scores. Students in states with policies promoting students’ health, e.g., regular participation in physical education, appropriate nutritional culture, services to address students’ physical and/or mental health needs and harassment prevention, demonstrated higher academic scores on the National Assessment of Educational Progress (NAEP) tests than students in states that did not have health-promoting policies. In Ontario, an examination of the effect of Ophea’s Living Schools Initiative showed that increased focus on students’ health in schools led to positive changes in their academic performance, as measured by Education Quality and Accountability Ofﬁce (EQAO) test scores. (21)

The requirement to provide instruction on health-related topics has long been an important part of the education sector’s mandate. Public health units have played a key role in supporting this mandate through the development of curriculum resources, targeted classroom teaching related to sexual health and drug use and the promotion of health awareness campaigns. Until recently, these efforts focused on classroom instruction or addressed single issues such as abstinence, smoking and drugs. The Pan-Canadian Joint Consortium for School Health reports that “research has shown that it is more effective to work more comprehensively, that is, integrating policies and practices that support student learning, health and well-being into every aspect of the school environment.” (22)

The OPHS Requirements state that boards of health shall use a comprehensive health promotion approach when working with school boards and schools to inﬂuence the development and implementation of healthy policies and to support the creation or enhancement of supportive environments. Comprehensive health promotion approaches are informed by the Ottawa Charter for Health Promotion (23), the Population Health Promotion Framework (24) and the WHO Jakarta Declaration. (25) The ﬁve key health promotion strategies outlined in the Charter include:

Building healthy public policy
Creating supportive environments
Strengthening community action
Developing personal skills
Reorienting health services

These strategies combine diverse, multifaceted approaches to promote self-care, mutual aid and healthy supportive environments. The Charter emphasizes both individual and community empowerment and engagement. Building personal skills, small-group development, community development, advocacy for healthy public policies and political action are fundamental to fostering meaningful participation of various partners in the school community. Comprehensive health promotion approaches engage the whole school community in identifying its strengths, concerns and issues and in implementing strategies to create a healthy, supportive environment for students and their parents and school staff.

c) Provincial Policy Direction, Strategies and Mandates for a Comprehensive Health Promotion Approach with Educational Settings

Across Canada, a comprehensive health promotion approach in school settings (also referred to as Healthy Schools, Comprehensive School Health, or Health Promoting Schools) has been gaining momentum, especially with the 2004 federal-provincial agreement to promote healthy school communities and its commitment to create the pan-Canadian Joint Consortium for School Health (JCSH) to:

Strengthen cooperation among ministries, agencies, departments and others in support of healthy schools.
Build the capacity of the health and education sectors to work together more effectively and efﬁ ciently.
Promote understanding of and support for the concept and beneﬁts of comprehensive school health initiatives. (26)

This JCSH focuses on knowledge development, leadership and capacity-building to support the advancement of comprehensive school health approaches.

Comprehensive school health is an “internationally recognized framework for supporting improvements in students’ educational outcomes while addressing school health in a planned, integrated and holistic way.” According to the JCSH, comprehensive school health is not just about what happens in the classroom. Rather, it encompasses the whole school environment with actions addressing four distinct but interrelated pillars that provide a strong foundation for comprehensive school health:

Social and physical environment
Teaching and learning
Healthy school policy
Partnerships and services

When actions in all four pillars are harmonized, students are supported to realize their full potential as learners – and as healthy, productive members of society. (26)

While different countries, jurisdictions and organizations articulate these pillars in slightly different ways, they all share the same underlying strategies identiﬁed in the Ottawa Charter for Health Promotion. (23) Other terms may be used to represent a comprehensive school health approach; however, there are more commonalities than differences among these as illustrated in Table 1. In Ontario, Health Promoting Schools, Healthy Active School Communities and Healthy Schools are terms that have been used since the early 1990s. Since 2005, the Ontario Ministries of Education and Health Promotion have been members of the JCSH and advancements have been made provincially to support a comprehensive school health approach. Of primary relevance was the introduction of the Foundations for a Healthy School framework by the Ministries of Education and Health Promotion in December 2006, leading to the adoption of Healthy Schools by many Ontario public health units. (27) This framework identiﬁ es four components to address health-related topics using a comprehensive approach:

High-quality instruction and programs
A healthy physical environment
A supportive social environment
Community partnerships

foundations for a healthy school chart

The Foundations for a Healthy School framework can be located at http://www.edu.gov.on.ca/eng/healthyschools/foundations.pdf

Healthy school policies are embedded within each of these four components. Additionally, the framework identiﬁ es health-related topics that are aligned with curriculum expectations for elementary and secondary school students, and that are relevant to student well-being. The health-related topics include healthy eating, physical activity, bullying prevention, personal safety and injury prevention, substance misuse prevention, healthy growth and development and mental health.

See Appendix A for an overview of deﬁnitions of the most common models.

Provincial Healthy Schools initiatives that are consistent with and support a comprehensive school health approach include:

The launching of the Healthy Schools Recognition Program.
The introduction of Daily Physical Activity (DPA) and supporting tools such as the DPA e-learning module.
The School Health Environment Survey implemented in the 2007/2008 school year.
The introduction of the Healthy Foods for Healthy Schools Act.
The revised Health and Physical Education curriculum, released January 2010.

More information on provincial Healthy Schools initiatives can be found at www.ontario.ca/healthyschools. The following table describes various comprehensive school health models, noting commonalities among models. Each model addresses the identiﬁed “pillars” of comprehensive school health with slight variation.

Table 1: Commonalities among Healthy School Approaches
MODEL	COMPONENTS
Foundations for a Healthy School (Ontario)	High quality instruction and programs	A healthy physical environment	A supportive social environment	Community partnerships to enhance access to resources and services	* Healthy policies embedded in each of the four components
Comprehensive School Health (Joint Consortium for School Health)	Teaching and learning	Social and physical environment		Partnerships and services	Healthy school policy
Comprehensive School Health (Canadian Association for School Health)	Teaching and learning	Healthy physical environment	Supportive social environment	Health and other support services	* Healthy policies and effective linkages with partners are embedded in each of the four components
International Union for Health Promotion and Education (IUHPE)	Individual health skills and action competencies	School’s physical environment	School’s social environment	Health services Home and community links	Healthy school policies
Focusing Resources on Effective School Health (FRESH-WHO)	Skills-based health education	Safe water and sanitation	Health-related school policies [school policies promoting good health and a non-discriminatory, safe and secure physical and psychosocial environment] Pupil awareness and participation	Access to health and nutrition services Partnerships between education and health Community partnerships	Health-related school policies
Health Promoting Schools (WHO)	Provides skills-based health education	Strives to provide a safe, healthy environment		Engages health and education officials, teachers and their representative organizations, students, parents and community leaders in efforts to promote health; provides access to health services; Strives to improve the health of the community	Implements health-promoting policies and practices
Health Promoting School (Australia)	Curriculum, teaching and learning	School organization, ethos and environment		Partnerships and services	* Policies contribute to achieving health promoting schools
Coordinated School Health Program (U.S.)	Health education; physical education	Healthy school environment (physical and psychosocial; includes Nutrition Services)		Health services; nutrition services; counselling and psychological services; family/community involvement; health promotion for staff

Section 3. OPHS Requirements

The Ontario Public Health Standards (OPHS) state that boards of health “shall work with school boards and/or staff of elementary, secondary and post-secondary educational settings, utilizing a comprehensive health promotion approach, to inﬂuence the development and implementation of healthy policies and the creation or enhancement of supportive environments…” and that boards of health “shall increase the capacity of community partners to coordinate and develop local/regional programs and services.” In addition, the OPHS include speciﬁ c requirements for implementation of the mandate related to oral health, immunization, tobacco enforcement and food safety (see Section 4 for more detail). This School Health Guidance Document focuses primarily on elementary and secondary educational settings. We acknowledge that public health units currently provide varying levels of service and programming to post-secondary institutions, alternative, schools such as private, faith-based, correctional service sector and home school programs. These are brieﬂy considered below.

Post-secondary institutions:

The latter teen years and early adulthood can be very challenging for young people. The increasing independence that accompanies post-secondary education can result in engagement in risky behaviours. A recent study of student services in college, institute and university students and student services administrators in Canada (28) conﬁrmed the important role of health services in making post-secondary institutions healthy settings. Mental health, particularly depression, was the most frequently identiﬁed health concern, along with fatigue, stress and eating/weight/nutrition issues. Sleep deprivation, addictions, ﬂu and cold symptoms, a lack of physical activity, ﬁnancial concerns and life balance issues were also reported. These concerns are often inter-related and create a vicious cycle of academic, personal, ﬁnancial, lifestyle and health concerns that can impact academic performance. The study recommended that campuses reframe the ways in which they assist post-secondary students, as students learn how to enhance and maintain their own health within a healthy campus environment. Additionally, it was recommended that health be redeﬁ ned as:

Instrumental to the goals of student affairs and post-secondary education.
A tool for explaining and resolving important aspects of academic engagement and achievements.
An opportunity for new partnerships with students, collaborative projects and cross-campus coalitions.

A Population Health Promotion Model was recommended in creating a healthy campus and, for the most part, it aligns with a Healthy Schools approach. Public health programs and services can contribute to campus initiatives. Since 2005, the Edmonton Charter for Health Promoting Universities and Institutions of Higher Education (29) (http://www.virtualwellness.ualberta.ca/docs/VW/CharterHealthPromoting.pdf) has guided some colleges and universities in incorporating health promotion into their strategic plans and in developing policies, systems and practices to create and maintain healthy learning, working and living environments.

Private and home school considerations:

All schools, whether public, private/independent or home schools, have access to a wide range of public health services. Health units may consider how to communicate the public health Core Services that are available to all schools or members of the public, for example, infectious diseases prevention and control, immunization, cafeteria inspections, drinking water testing, oral health, Smoke-Free Ontario Act enforcement, sexual health services/support, fact sheets/guidelines, newsletter articles, telephone information lines for consultation, health unit website and web-based resources, etc.

Health units may also communicate Elective Services that may be offered upon request to private/independent and home schools. These might include Healthy School Committees; small group programs; youth leadership programs; Food Safety Courses; travel health clinics; prenatal, breastfeeding, parenting, child/family health or smoking cessation programs; curriculum support/continuing education for teachers; and one-on-one consultation and referral. Offered Elective Services should be based on assessment of community needs and available resources.

Schools as workplaces:

Children and youth share the school setting with teachers and other personnel. Canada’s schools are the workplace for 20% of our population including over 400,000 employees (9). “School employees are susceptible to the same health risks and concerns that affect students and many of these health risks are the same as those experienced by adults in other worksites” (30; p 558). The creation of a Healthy School incorporates health promotion into the culture of the worksite, thus providing an ideal opportunity to improve faculty and staff well-being. It is possible to use similar comprehensive workplace health promotion strategies to engage the participation of school staff and administration to address staff health concerns. These efforts can often complement the activities of the school’s occupational health and safety committee. Public health staff members responsible for workplace wellness are well positioned to provide appropriate resources and consultation. For further information and tools on comprehensive workplace health, please see http://www.thcu.ca/Workplace/Workplace.html.

Alternative educational settings:

Alternative education has been identiﬁed as a key protective factor to prevent or intervene in early school leaving. (31) “Alternative schools are designed to serve a speciﬁc population, such as youth with disabilities, or unique learning or behavioural issues, teenage parents, or potential school leavers. Special attention is paid to the individual academic and social needs of each student, as well as to how these needs are connected with the successful attainment of a high school diploma” (31; p 78). Given the range of reasons youth may choose or beneﬁt from an alternative education setting, an opportunity exists for mental health promotion approaches to be incorporated into existing programs that enhance a young person’s sense of engagement, connectedness and positive sense of self. Whenever possible, public health units should strive to provide support to these programs, as they target a population of youth that can beneﬁt from prevention and health promotion services.

Elementary and secondary school settings:

The recommended approach described in this Guidance Document is based on evidence-informed models intended primarily for publicly-funded elementary and secondary school settings, although, as noted above, there is application in other school settings.

OPHS Requirements for School Settings

The OPHS indicate a requirement for public health units (PHUs) to work with schools to deliver the following programs:

Chronic Disease Prevention (addressing healthy eating, healthy weights, physical activity, comprehensive tobacco control, alcohol use and exposure to ultraviolet radiation)
Child Health (conducting Oral Health Surveillance and screening)
Vaccine Preventable Diseases in accordance with the Immunization of School Pupils Act and the Infectious Diseases Protocol, 2008

In addition to the above, the OPHS identify school boards and schools as a community partner to work with in the delivery of the following programs:

Prevention of Injury and Substance Misuse
Reproductive Health
Child Health
Sexual Health, Sexually Transmitted Infections and Blood-Borne Infections
Infectious Diseases Prevention and Control
Health Hazard Prevention
Emergency Preparedness

A more detailed discussion on the program standards can be found in Section 4 of this Guidance Document, which emphasizes the importance of the school setting to facilitate an integrated approach to promotion of child and youth health.

A note about mental health: While mental health is not noted as a speciﬁc OPHS program, the promotion of positive mental health of children and youth is recognized as fundamental to the development of healthy behaviours by children and youth. Additional Guidance Documents discuss information about mental health and the mandate of public health.

a) General Considerations in Using a Comprehensive Health Promotion Approach with Educational Settings

i) Foundational Principles

Public health has a long tradition of supporting school health in Ontario. In the context of planning and delivering public health programs and services to meet the needs of local boards of education and their schools, boards of health are guided by the principles of need, impact, capacity, and partnership and collaboration. A Healthy Schools approach aligns itself with these principles and guides the provision of public health services in school boards and schools.

(1) Need

As outlined in the OPHS, programs and services should be tailored to the local community context, including school communities. Children and youth are deﬁned as priority populations based on identiﬁed needs. Data and information about individual school communities can be very useful to inform the planning and delivery of public health services and programs. The community assessment or consultation process inherent in a Healthy Schools approach can assist public health staff to offer appropriate programs that will respond to the speciﬁc priorities of the school board or individual schools. Ongoing population health assessment and surveillance of school communities should be conducted to identify speciﬁc needs or concerns, and to generate evidence to guide program and service development.

(2) Impact

The OPHS state that boards of health should “strive (…) to inﬂuence broader societal changes that reduce health inequities and disparities by coordinating and aligning programs and services with those of other partners.” Public health programs and services play an important role in supporting the goals of the education sector, that is, the academic achievement of all children and youth. The Healthy Schools approach provides an opportunity for public health to partner not only with the education sector, but also with other community partners such as youth justice, social and health services and recreation programs that often intersect with schools. Collaboration and partnership are at the heart of the Healthy Schools process and encourage the planning and implementation of a variety of activities that promote wellness and resilience within young people and their families. Many prevention programs and services targeting children and youth and their families can also be effectively and efﬁciently delivered in schools. School-based initiatives focusing on issues such as substance use prevention, physical activity, healthy eating and mental health promotion often engage families and the surrounding community. These can have a powerful “cascading” effect on improving awareness and knowledge in the general population. (32)

Given the size and diversity of the number of school boards/authorities responsible for education in Ontario, a ﬂexible “systems” approach should be considered when implementing Healthy School initiatives. The number of schools per public health region ranges from 29 to 808, and the number of school boards that each public health unit interacts with ranges from 2 to 10. (33) Assessment to identify needs and set priorities based on capacity is therefore an important step in a comprehensive approach to working with schools.

Failure to recognize, understand and address the priorities of the education sector while attempting to implement the public health mandate could lead to potential adverse consequences. The public health system’s priorities include the promotion of a healthy population, whereas the education system’s priority is to ensure a well-educated population with strong literacy, numeracy and other academic skills. It should never be perceived that these priorities are mutually exclusive; in fact, education is considered a social determinant of health, while good health is a contributor to better educational success. There is a need to link health promotion interventions to the primary role of the school in developing the educational skills and knowledge base of young people. (34–35) Public health units also need to ensure that public health programming and resources support the Ontario curriculum. When developing public health resources or school-based campaigns, educators with relevant expertise and experience need to be engaged early on in the development so that programs have the expected impact on learners. Buy-in from school staff ensures improved programming for students and better coordination of efforts to address health concerns.

See Section 3.c for further discussion of the impact of Healthy Schools on the determinants of health.

(3) Capacity

In order to effectively manage public health programs and services, it is essential to understand the capacity of the public health unit and the resources required to successfully support the implementation of Healthy Schools in their jurisdiction.

It is understood that public health units may not have the capacity to offer support for Healthy Schools in all schools within their jurisdiction. Health units will need to determine how to prioritize schools for more in-depth health promotion (e.g., schools at a point of readiness, highest need schools, school boards’ priority schools, etc.). In order to develop or maintain the capacity to facilitate and sustain healthy school communities, public health units may:

Devise strategies for training public health and school staff, students and parents.
Build on initiatives that are being implemented in school boards or schools, such as implementation of the revised Health and Physical Education Curriculum, School Food and Beverage Policy, Character Development, Safe Schools, Parent Involvement, Student Support Leadership Initiative for mental health and early childhood education initiatives, such as Schools as Hubs.
Build the infrastructure and policy support required to sustain comprehensive school health promotion.

The skill sets required by public health staff to support a comprehensive school health approach are congruent with the Core Competencies for Public Health in Canada Release 1.0. (36) Knowledge and skills in the following areas are all relevant to providing leadership and support for Healthy Schools:

Assessment and analysis of information
Program planning, implementation and evaluation
Facilitating partnerships and collaboration
Effective interaction and communication with diverse individuals, groups and communities

(4) Partnership and Collaboration

The development of positive working relationships with all school stakeholders (students, parents, school staff and administrators, school council, school board staff and community partners) is fundamental to all Healthy Schools work and critical for success. It is important to establish and maintain relationships at all levels. Strong relationships are needed to proceed with creating health-supporting environments, developing healthy policies, curriculum resources, or any other aspect of health promotion work.

Partnership development should:

Be based on a mutual understanding of the roles and responsibilities of all partners;
Be based on common goals and strong relationships among all school stakeholders (students, parents, school staff and administrators, school council, school board staff and community partners);
Have time to develop; and
Be ﬂexible and adaptable.

ii) Capacity-building

Capacity-building within education, health and other community sectors is an important aspect of the work public health staff do in their efforts to create and support healthy supportive environments. Capacity-building supports the development of sustainable skills, organizational structures, resources and commitment to enhanced outcomes. Several standards in the OPHS refer to increasing the capacity of community partners to coordinate and develop local/regional programs and services. Working with school boards and schools provides an ideal opportunity to reach a majority of the children, youth and their families. Hence, the main focus of public health’s efforts should be to increase the capacity of partners within both the school board and individual schools to identify their priority health-related issues or topics, and to develop and implement their own plans for taking action on these. Building on the successes of Western Australia’s initiatives, some public health units and school boards have organized a district-wide workshop for members of Healthy School Committees and also provide manuals, sample activities and web-based resources to support planning and implementation. Ongoing consultation is also provided as needed. (37, 38)

While there is variability in the readiness of boards of education and/or schools to engage in a Healthy Schools approach, the link between a student’s health and optimal learning is prompting some principals to request public health support in undertaking this work. Additionally, education professionals are actively promoting Healthy Schools. For example, the Canadian Teachers’ Federation has created a publication entitled Health and Learning to highlight the importance of health promotion in the education sector. (39) The spring 2009 issue of the Canadian Association of Principals Journal focused on Healthy Schools. (40) As well, some school boards in Ontario, such as the Thames Valley District School Board, have adopted a Healthy School policy, demonstrating a recognition that Healthy Schools contribute to student learning and a healthy and safe learning environment.

iii) Recommended Healthy School Process

Table 2 summarizes the process elements of effective Healthy School practices that have been drawn from successful global Healthy School initiatives. Note that while there are variations in the processes used by various jurisdictions, they all offer similar recommendations for successfully planning, implementing and evaluating Healthy Schools.

Table 2: Recommended Effective Practices Related to the Process of Creating Healthy Schools
RECOMMENDATIONS	REFERENCE
The following steps have been shown to be necessary in starting a health promoting school (HPS) Develop a supportive government/local authority policy for a HPS. Achieve administrative and senior management support. Create a small group that is actively engaged in leading and coordinating actions including teachers, non-teaching staff, students, parents and community members. Conduct an audit of current health promoting actions according to the six elements of HPS [See Table 1]. [NOTE: In Ontario, refer to the four components of the Foundations of a Healthy School framework.] Establish agreed-upon goals and a strategy to achieve them. Develop a HPS Charter [commitment to a shared vision]. Ensure appropriate staff and community partners undertake capacity-building programmes and have opportunities to put their skills into practice. Celebrate milestones, e.g., the launch of the HPS Charter. Allow 3–4 years to complete specific goals.	International Union for Health Promotion and Education (2009). Achieving Health Promoting Schools: Guidelines for Promoting Health in Schools. Retrieved May 12, 2009, from: http://www.iuhpe.org/uploaded/Publications/Books_Reports/HPS_GuidelinesII_2009_English.pdf (14) Guidelines for Health Promoting Schools (HPS) have been produced based on analysis of research, evaluation evidence and quality practices and initiatives of international organizations.
Building local support Establish a School Health Team. Assemble a Community Advisory Committee. Team-build and network (create the vision of a HPS; signing a charter). Taking action Review current school health promotion efforts. Assess community health problems, policies and resources. Find opportunities for action. Set goals. Define objectives. Develop an action plan. Demonstrate progress (process evaluation; outcome evaluation; demonstrate, publicize and celebrate your school’s achievements). Obtain training and technical assistance. Link local efforts to larger initiatives.	World Health Organization. (2000). Local action: Creating health promoting schools. Retrieved April 19, 2009, from: http://www.who.int/school_youth_health/media/en/sch_local_action_en.pdf (41)
Implementing coordinated school health programs in local schools (U.S.) Establish school-based leadership (school principal or vice-principal). Identify key players. Establish a Healthy School Team and select a coordinator. Get “buy-in” from other school staff. Establish a common language. Set up a safety net (to deal with barriers or conflict). Map existing school-based and community-based resources. Identify student, family and staff needs. Identify programmatic needs. Develop an implementation and coordination plan. Identify existing and potential sources of funding. In addition, Establish communication mechanisms Invite participation Establish subcommittees Celebrate and publicize successes	United States Fetro, J. V. (1998). Implementing coordinated school health programs in local schools. In E. Marx & S. F. Wooley & D. Northrop (Eds.), Health is academic: A guide to coordinated school health programs (pp. 15-42). New York: Teachers College Press. (42) Carlyon, P., Carlyon, W., & McCarthy, A. R. (1998). Family and community involvement in school health. In E. Marx & S. F. Wooley & D. Northrop (Eds.), Health is academic: A guide to coordinated school health programs (pp. 67-95). New York: Teachers College Press (43)
Healthy School Planner (JCSH) Form a Team Assess your school environment Plan and Act to make it better Celebrate your achievements	Pan-Canadian Joint Consortium for School Health – Healthy School Planner. Retrieved from: http://www.jcsh-cces.ca/ (26)
Working Towards a Healthier High School – 6 Steps for Students Step 1– Get started (establish a healthy school committee; do a school scan of existing activities). Step 2 – Do your homework to determine what's important to your school. Step 3 – Develop a plan. Step 4 – Make it happen (involve other students). Step 5 – Review and identify next steps. Step 6 – Celebrate your success.	Ontario Healthy Schools Recognition Program. Retrieved from: http://www.edu.gov.on.ca/eng/healthyschools/sixSteps.html (27)
1. Community Consultation Schools utilize community consultations, partnerships and committees of stakeholders to identify a common vision for their school community, complete with goals, objectives and a clear level of commitment. 2. Declaration and Commitment Schools sign a Charter to declare their school community's intent to work towards a comprehensive Healthy Schools approach. The Charter is signed by a minimum of three “pillar partners” representing the school, public health and a recreation/sport provider. 3. School Community Action Planning and Implementation Schools establish and implement local action plans that include activities that reflect the four components of Ontario’s Foundations for a Healthy School framework. 4. Evaluation and Celebration Schools track planning and implementation activities and celebrate their school community's achievements.	Ophea, Living School initiative.(44)

See Appendix B for a simpliﬁed handout describing the recommended Healthy School process: The A, B, Cs of Healthy Schools.

The processes in the table above have informed the next section on recommended practices that public health staff should consider in planning and delivering their school health programs and services within a comprehensive health promotion approach. Appendix C also contains lessons learned from around the world regarding comprehensive health promotion in schools. (45, 14, 46) Many public health units have built their work on evidence from sources listed above and have gained knowledge, skills and experience in implementing Healthy Schools. In addition to the models above, research describes the involvement of public health nurses (PHNs) in building structures and processes that enable school communities to take action for health. (47, 48) Additional roles for PHNs reported in the literature include: participating on school teams to address health, assisting with the needs assessment process and supporting program co-ordinators (47); supporting a community development approach (49, 50); securing commitment to establishing a healthy school committee, assisting in formation of the committee and facilitating the needs and strengths assessment, a planning process and committee meetings. (50, 51)

In Ontario, public health staff such as dietitians, dental health professionals, public health inspectors, health promoters, epidemiologists and nurses have contributed their particular areas of expertise to promote the health of students and school staff. Public health staff members have worked with schools to address speciﬁc health issues such as healthy eating, physical activity promotion, safety issues and substance use prevention, as well as to support a broader Healthy Schools approach.

b) Speciﬁc Considerations for Public Health Service Delivery in Schools

i) Strengths-based Approach

Health promotion work in educational settings involves partnering with school boards and schools to build on their strengths rather than focusing on their deﬁcits. Effective practice involves a strengths-based approach in working with children and youth, parents, school boards, schools and communities.

Most school boards and schools already have many health-promoting policies and activities in place. Health units should be aware of these and seek to build on strengths and facilitate continuous improvement in health-related areas. Section 3.d provides a further discussion on building developmental assets and protective factors that foster the healthy growth and development of children and youth and the creation of supportive school environments.

It is also important to recognize stakeholder expertise. Integral to the establishment of good working relationships between public health and education is the recognition that each sector has expertise that can contribute to Healthy Schools. Public health workers are trained in speciﬁc disciplines, for example, nursing, nutrition and epidemiology that include knowledge and content expertise, as well as planning and health assessment skills. Educators are trained in educational theory and are skilled in working with children and youth as students, are knowledgeable in curriculum requirements and interact regularly with students and parents in their community. Students, parents and other community stakeholders also may have professional and/or experiential expertise that would inform and support Healthy Schools action.

It is also important to understand that a long-term commitment is needed on the part of both health units and school boards/schools, as sustained change within schools takes several years to become ﬁ rmly established.

ii) Coordination within Health Units

A Healthy Schools approach facilitates the integration of public health programs and services that support areas of focus for change or action identiﬁed by the school. Moreover, this approach promotes a focus on protective factors related to multiple risk-taking behaviours. It is important to create and maintain organizational structures within public health units that allow staff from various programs and services to come together and plan optimal ways to organize public health services to sustain healthy schools. The following are important internal considerations to enable meaningful and sustainable planning:

Secure commitment from leaders of the Health Unit (e.g., senior and middle management).
Designate a School Health Manager whose role includes facilitating cross-program communication.
Allocate staff-level School Health Coordinator position(s) to liaise formally with school boards.
Establish a committee with representatives from all departments and programs to coordinate work with schools and increase effectiveness and efﬁ ciency.
Establish other internal coordinating committees as needed for speciﬁ c purposes.
Work with school boards to establish a process that prioritizes schools that will receive more in-depth health promotion support (e.g., stage of readiness, high need, school board’s priority).
Designate health unit staff to function in a liaison capacity with prioritized schools.
Ensure that health unit staff members with content-speciﬁc expertise are available to support schools with issue-speciﬁ c planning.
Equip health unit liaison or program staff to provide appropriate advice and referrals to link children/youth, parents and school staff to community programs and services.
Engage youth meaningfully in all stages of planning, implementation and evaluation (at school, school board, community and health unit levels).

Other Considerations Related to Internal Capacity:

Staff roles: Health unit staff may be “assigned” to schools to provide/support a wide range of activities in schools, such as:

Linking schools with a variety of health campaigns/programs/community agencies.
Providing curriculum support/health resources to support implementation of the curriculum.
Promoting and facilitating Healthy School Committees.
Enhancing understanding of the Healthy School concept.
Facilitating staff and/or student counselling (secondary prevention/one-one/sexual health services).
Supporting school-based clinics.
Fostering youth engagement and youth leadership.
Providing in-service education sessions for all staff working with schools on common aspects such as the comprehensive school health/Healthy Schools approach.

Geography and catchment area: Large rural areas may require signiﬁcant travel within catchment area, which will impact capacity to provide in-school support.

Establish multiple partnerships when there are inconsistent boundaries for public health and school board regions – it is generally the norm that health units work with multiple school boards, and there may be instances when a number of health units work with one school board. Where this occurs, coordination between health units is encouraged to enhance the clarity and effectiveness of public health messaging and programs.

iii) Coordination with School Boards

The OPHS acknowledge that effective delivery of public health programs and services requires partnerships with various sectors. Public health units foster the creation of a supportive environment for health in schools by engaging boards of education and their schools, and including staff, students, parents and community partners, in the assessment, planning, delivery, management and evaluation of programs and services. Public health units may also participate in community-wide planning to maximize the community’s capacity and skills to support and sustain schools in their efforts to become healthy school communities. To this end, the following strategies have been identiﬁed as effective:

1)Build solid working relationships between Public Health Units and School Boards. The considerations noted in Section 3.a all point to the need for effective working relationships between relevant health and education systems to support a Healthy School approach. In the context of public health’s role, relationships with school boards are essential to ensure that community needs are being met, priorities identiﬁed and coordination is ongoing. It is also appropriate to consider that one aspect of public health’s role is to draw upon schools’ assets and help schools recognize their potential to support health. This recommendation is congruent with establishing and maintaining effective partnerships and collaborations, a core competency for public health workers. (38)

Secure support for healthy schools from superintendents and other school board contacts whose work relates to school health. Health units have collaborated with school boards to develop a Healthy School policy or other topic-speciﬁ c policies.
Explore, with school boards, how to integrate healthy schools into their board and school-level planning processes (e.g., school improvement plans, safe schools, character education, student engagement, student success, parent engagement, environmental education). A comprehensive school health approach can be used for schools at different stages of engagement around health, but requires exploration to determine the greatest opportunity to advance comprehensive school health.
Establish a committee with school board(s) and health unit staff to coordinate local healthy school initiatives (may also include other community partners).
Identify in each school board a “point person” or main contact and/or a list of appropriate contacts for speciﬁc healthy school initiatives that health unit staff can connect with.
Provide school boards with the name of a health unit “point person” or main contact for Healthy Schools and/or a list of appropriate contacts in various health unit departments.
Ensure questions are addressed in a timely manner to increase the likelihood of a mutually beneﬁ cial working relationship.
Hold meetings with School Board Director, Medical Ofﬁcer of Health, School Board Superintendent and PHU Directors/Managers to share and coordinate initiatives related to school health.
Develop a communication plan with schools and school boards that includes both regular communication between senior administration in the health unit and school boards as well as day-to-day contacts and referrals. Decide upon a process to secure necessary board-level approval/endorsement of messages. Discussion of new programs or approaches, garnering support for comprehensive approaches and pursuing opportunities for ﬁnancial or other partnerships contribute to a supportive and open relationship at the director/superintendent to MOH director/manager level.
Be aware of board of education research and evaluation protocols and allow sufﬁcient time for review and approval of any public health surveys or evaluations conducted in schools.

iv) Coordination within Schools

An ideal coordinating committee in an elementary school includes representatives from school administration, school staff, students, parents and relevant community partners, such as public health, recreation, police, etc.
An ideal coordinating committee at a secondary school includes primarily students and a teacher advisor, with support from school administration, parents and relevant community partners, including public health, as appropriate.
Provide schools with the name of their health unit “point person” or main contact for Healthy Schools and/or list of appropriate contacts in various health unit departments.

It is helpful for public health staff to understand and value the school environment, which includes:

The culture of the school.
The school improvement/effectiveness plans identifying school priorities that inﬂuence the allocation of resources.
The strengths and needs of the school.
The policies (e.g., curriculum and program expectations), procedures (e.g., internal administrative procedures), processes (e.g., communication systems, school councils) and structures (e.g., principal leadership, lead teacher, divisional/school wide initiatives) of the school.
The role of the school council/parents in the decision-making process.
The school as a setting to promote not only the health of children and youth, but of school staff as well.
The roles and expertise of school staff in working with students, families and communities.

The following strategies have been identiﬁed as effective for coordination with schools.

Foster relationships with principals: Principals have responsibility for what happens in each school and are thus key inﬂuencers. Establishing a strong relationship with principals can facilitate an understanding of why the Healthy Schools approach is relevant for every school, and how it can be implemented to meet the needs of each school. Principals can support Healthy Schools by identifying student health and health promotion as school priorities, encouraging staff buy-in, providing updates at staff meetings, allocating teacher time for committee work and organizing health initiatives or appointing a teacher champion.
Foster relationships with school staff: Teachers make critical contributions to healthy school committees and have been identiﬁed as important champions of Healthy Schools. (41, 42, 51, 53) It is important to consider the workload and the strengths of individual teachers when recruiting them for their assistance. Aligning Healthy Schools with what a teacher may be covering in the curriculum is also an effective strategy. Other successful strategies include encouraging a shared responsibility among several teachers or staff, for example, the health and physical education teacher, the school chaplain, child and youth worker, guidance counsellor, or student council advisor. Health can easily be addressed in various school subjects such as science, social studies, technology and the arts. The Healthy Schools approach offers an opportunity for teachers to create a healthier learning environment in their individual classrooms and to foster school-wide youth engagement.
Engage students: Students have valuable perspectives and should be engaged to offer input to ensure school health programs and services are meaningful. They should be viewed not only as recipients of health promotion efforts, but as partners, with valid views and the ability to make and carry out decisions. (56) Students are willing and able to participate in the process of community development.

Recommended approaches to support student engagement include:

Identify student engagement resources available through the school boards and Ministry of Education
Engage students to seek out ideas about healthy school priorities when working with schools. Consider student ideas provided at http://www.edu.gov.on.ca/eng/healthyschools/tipsStudents.html.
Invite students to chair, co-chair or participate in Health Action Teams/Healthy School Committees.
Ensure that adults enable student voices and student actions on identiﬁed issues/concerns.

Foster relationships with school council chair(s): The school council provides a voice for parents on several school matters; every school is mandated to have a school council. Engaging the school council early on provides an opportunity for parents, staff and students to support a Healthy School Committee and to participate in any health initiatives or celebrations that are organized.
Engage parents: Parent engagement may vary widely from school to school, but parents are important stakeholders and are interested in what happens in school settings where their children spend a good part of each day. According to the Ministry of Education, “research clearly indicates that good schools become better schools when there is a strong connection with parents as part of the learning community. The positive results of a genuine partnership between parents and schools include improved student achievement, reduced absenteeism, better behaviour and restored conﬁdence among parents in their children’s schooling.” (53) Parents can be engaged through school councils and associated committees, but innovative approaches may also be required. The Ministry of Education is committed to parent engagement. Visit http://www.edu.gov.on.ca/eng/parents/ for more information about why and how to engage parents.
Maintain knowledge of and provide referrals to appropriate community and provincial services: Refer to and provide information about existing Public Health and school board support services, existing community support services and existing provincial supports that are available and relevant.
Ensure familiarity with the Ontario curriculum, in particular the Health and Physical Education Curriculum (revised 2010): With High-Quality Instruction and Programs as one signiﬁcant pillar of the Ontario Foundations for a Healthy School framework (and other comprehensive school health models), curricula that address health topics are fundamental supports to draw upon and enhance to further facilitate Healthy Schools activities. The revised Health and Physical Education curriculum includes requirements that overlap with many public health requirements. Other curriculums, such as Science and Technology, have requirements that are relevant for health. Find the Health and Physical Education curriculum at: http://www.edu.gov.on.ca/eng/curriculum/elementary/health18curr2010.pdf.

v) Coordination with Community Partners

Community partnerships are essential in the Healthy Schools approach. As the school identiﬁes health issues, it is important to consider other community resources or agencies that might be able to assist with a particular issue. Public health staff members are often very aware of other organizations or agencies that can provide technical expertise, materials or services that complement a Healthy School Committee’s plan of action. For example, police, recreation specialists, health professionals and owners of local businesses can provide human resources, training, educational materials and equipment on a number of topics such as safety, physical activity, nutrition, mental health, substance use and the physical environment.

vi) Ensuring a Common Understanding of the Healthy Schools Approach

A comprehensive school health approach engages all school stakeholders in the following key steps of a planning process:

1. Create a shared vision for a healthy school
- Establish common goals, shared ownership, responsibility and commitment.
2. Assess strengths and needs of the school community
- In collaboration with school boards/schools, plan processes to assess the strengths and health-related needs of the school population to inform planning and program and policy development.
- Share information related to trends and priority populations with the school board/school staff.
- Explore and build on existing strengths, resources and processes already in place in the school that are health-supporting.
- Explore areas where improvements could be made.
3. Prioritize the issues
- Collaborate with school board/school stakeholders to identify which area they wish to take action on ﬁrst.
4. Develop a plan
- Assist school stakeholders to create a comprehensive plan that includes areas for action in each of the four components of the Healthy Schools approach.
- Share best practices and evidence related to health promotion and disease prevention with relevant stakeholders to support program planning.
- Build ﬂexibility into plans to allow for changing circumstances.
5. Implement the plan
- Promote access to public health, school board and other community resources, including programs and services.
6. Monitor/evaluate
- Document initiatives, including evaluation, in a project plan.
- Endeavour to collect process and outcome evaluation data on programs and services that are carried out.
- Build relationships with community researchers, academic partners and other appropriate organizations to support public health research and knowledge exchange.
7. Celebrate and communicate successes
- In collaboration with school boards and/or schools, plan networking/sharing/celebration/ communication opportunities.
- When possible, participate in Healthy Schools committee celebration activities.
- Encourage schools to submit information about their Healthy Schools initiatives to be recognized as part of Ontario’s Healthy Schools Recognition Program.

Examples of tools to support the process above are noted in Section 5: Resources to Support Implementation.

Health unit staff should have a solid understanding of the Healthy Schools approach and of their role in relation to its implementation. Invest time in in-servicing and debrieﬁng for public health staff involved in Healthy Schools work.

In collaboration with school boards, public health units can support the implementation of Healthy Schools by identifying and providing the necessary tools that will assist the school to move forward. These may include:

Tips on mobilizing a Healthy School Committee or integrating with an existing working group
Visioning questions/process
Agreement/statement of commitment
Assessment of school strengths and needs to assist in prioritizing issue(s)
Planning template
Activity report
Final year-end report/monitoring/evaluating tool
Minutes form
Recognition options (e.g., banners, plaques, newsletter items, media coverage)
Possible sources of funding or suggestions for low-cost ways to address goals

vii) Communications

Appropriate communication between public health and education partners is most effective when several strategies are employed.

Understand the school board and school-level process for relaying health-related messages to school board staff, principals, teachers, school staff, parents and students.
Determine the process for necessary board-level approval/endorsement of messages or materials.
Coordinate communications to school boards/schools to ensure they do not feel bombarded from numerous departments and that the approval process is followed by all programs/staff.
Use appropriate or common language and terminology. Both the health and education sectors have their own terminology, which in some cases is not well understood by the other sector. The fostering of strong relationships between the sectors and acceptance of sector priorities can help to increase public health workers’ and educators’ knowledge of each other’s appropriate language.

Develop strategies to promote discussion of and/or communicate health-related information/Healthy Schools successes/public health school activities to School Board personnel, school personnel, parents, students and community through channels that may include:

School board meetings
Director/supervisory ofﬁ cer meetings
Face-to-face meetings with principals
School staff meetings
School council meetings
Meetings with speciﬁc school subject groups (e.g., health and physical education department heads)
Health unit staff sitting as partners with school staff on coalition working groups
Telephone line for school health inquiries and/or speciﬁc curriculum support
Teacher representatives on health unit working groups (e.g., for reviewing or preparing new curriculum support)
Meetings between
- Communication departments of the school board(s) and health unit staff
- The coordinating person at the board of education and at the health unit on a regular basis
- The Director(s) of Education and/or board superintendents and the Medical Ofﬁcer of Health (MOH) or Associate MOH, once or twice a year
Coordinated “updates” from the health unit for principals’ meetings
A health unit newsletter for schools
Annual mailings to principals on health unit programs and services
Annual summary report to school boards of public health supports provided to schools during the school year
Linking schools to health campaigns/programs
School support section on health unit website
Contribute to content of Healthy Schools section on the school board’s website
Adapt and/or supplement national and provincial health communications strategies and/or develop and implement regional/local communications strategies in relation to various health issues.

c) Considering the Determinants of Health

Education is a key determinant of health that affects other determinants, such as employment, income, housing, health literacy and social status. Findings from several studies conﬁrm strong relationships between student health risks and education outcomes. (4, 15, 16, 31) Given the very high percentage of Ontario children enrolled in the education system, public health has an excellent opportunity to have a signiﬁcant impact on this population. The inﬂuence of multiple determinants of health becomes visible in school communities. Through inter-sectoral action, public health and the education sector can reduce barriers to healthy growth and development, social inclusion, academic achievement, literacy, food security, language and culture. It is possible to augment protective factors and mitigate risk factors in a child’s physical and socioeconomic environment within the home, neighbourhood and community, through the healthy, supportive environment of the school. (4, 6, 15)

Schools have been recognized as intervention settings or community hubs that can minimize barriers to access, thus promoting more equitable access to programs and services. As health-promoting settings, schools allow for efﬁcient and accessible delivery of important public health, social, recreational and health programs and services that can reduce or narrow health disparities for children, youth and their families. Some examples include offering education and skill-building programs that increase the personal health practices and coping skills of children, youth, school staff and their families; increasing access to health information in multiple languages and at an appropriate level of literacy; providing parenting classes to teen and adult parents; supporting the development of socially inclusive environments and healthy relationships; and ﬁnally, the development and implementation of healthy policies that will reduce health inequities.

The processes and structures of a Healthy Schools approach facilitate inter-professional collaboration, community engagement and partnerships that can impact the well-being of students, staff and parents.

French First Language Schools (FFL Schools)

Ontario is home to the second largest francophone population in Canada. Existing data shows that francophones in Ontario have unique social and health status characteristics that have an impact on the need for services in French. This population is increasingly heterogeneous. The percentage of francophones belonging to a racial minority has increased in every region of Ontario and immigrant francophones are more likely to be concentrated in the Toronto and Ottawa regions. (54) While boards of health are not subject to the French Languages Services Act (FLSA), this Act guarantees the right of French-speaking Ontarians to receive provincial services in French in 25 designated areas of the province. The OPHS states that “boards of health should bear in mind that in keeping with the FLSA, services in French should be made available to French-speaking Ontarians located in designated areas.” (p.6) A Guidance Document on French Language Services to support the Ontario Public Health Standards is available at http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/progstds/pdfs/french_ language_services.pdf.

FFL school boards often serve large geographic catchment areas that usually intersect with several public health units. A 2009 report on French language health services planning identiﬁed the province’s low capacity to support health promotion programs in French. FFL schools are particularly concerned about the lack of community services to support healthy school initiatives. (See full report at http://www.ﬂ sc.gov.on.ca/ﬁles/Special_Report.pdf.) It is recommended that public health units work with existing francophone networks, such as the Réseaux franco-santé, local ofﬁces of the Association canadienne française de l’Ontario (ACFO) and the provincial project Élargir l’espace francophone, the latter supported by the Ministry of Education, to help expand francophone spaces beyond schools.

d) Mental Health, Healthy Development, Protective Factors and Resilience

The mental health challenges of children and youth are a signiﬁcant public health issue and now constitute the most important group of health problems that children suffer, superseding all the other health problems in terms of the number of children affected and the degree of impairment caused. (55–56) The WHO (57) maintains that mental health is the foundation for well-being and effective functioning, and is intimately connected to physical health and behaviour in such a way that neither mental nor physical health can exist alone.

A child’s mental health has a signiﬁcant impact on learning. Factors that lead young people to take multiple health risks are likely to be intertwined with barriers to positive mental health and well-being or risk factors for mental illness. (58) Child and youth mental health is moving to the forefront of health policy on overall health and well-being. Both the Canadian Institute for Health Information (CIHI) (58) and the Public Health Agency of Canada (PHAC) (59) have proposed strategies and opportunities for promoting positive mental health among the Canadian population. In Ontario, the Ministries of Education and Children and Youth Services jointly launched the Student Support Leadership Initiative in 2007. This initiative is bringing together boards of education and community agencies to plan and deliver services and programs that will support the mental well-being of school-aged children. As well, the initiative aims to identify and link children with mental health concerns to appropriate services in schools and the community. Schools continue to be a setting where children and youth having, or at risk for developing, mental health difﬁculties are identiﬁed. Research has shown that the earlier a mental health intervention occurs, the higher the chance for a successful outcome.

The fact that 70% of mental health problems have their onset during childhood and adolescence underscores the importance of public health involvement in mental health promotion. (5) Without effective prevention and intervention strategies, childhood mental health challenges lead to distress or impairment throughout adulthood, with signiﬁ cant costs to society. (6) The Mental Health Commission of Canada offered a number of recommendations to make the school a site for effective delivery of mental health services, including prevention and mental health promotion. (5)

The research evidence for a public health strategy to improve the mental health of Canadian children identiﬁ es four public policy goals:

Promote healthy development of all children.
Prevent mental disorders and reduce the number of children affected.
Treat mental disorders more effectively to reduce distress and impairment.
Monitor outcomes to ensure the effective and efﬁcient use of public resources. (6)

Mental health promotion for children and youth should focus on supporting individual resilience, creating supportive environments and addressing the inﬂuence of the broad determinants of mental health. (58) Public health staff should be aware of the stigma associated with mental health issues when integrating mental health promotion within health promotion programs. Stigma is a very real barrier that keeps youth devalued, isolated and reluctant to seek help. Opportunities present themselves within the school setting for public health staff to educate school staff about the impact of stigma, as well as examining personal beliefs and attitudes that may be perpetuating stereotypes around mental health.

A healthy, supportive school environment is especially critical to a young person’s mental well-being. For children and youth, feeling connected to school is related to positive physical and mental health. (60) The Healthy Schools approach contributes to the healthy growth and development of children by creating safe, caring environments that facilitate student engagement in learning and a sense of belonging and connectedness to the school. Research has reported that youth who feel connected to their school and are engaged in structured activities (ranging from extra-curricular school involvements to community service to organizational work in their church or community) are:

Less likely to use cigarettes, marijuana, hard drugs and alcohol.
Less likely to engage in risky sexual behaviour or become pregnant.
Less likely to engage in violent behaviour or be arrested.
Less likely to drop out of school.
More likely to complete a college degree than youth who were not engaged in these kinds of activities. (60–63)

The literature about developmental assets conﬁrms these ﬁndings. According to Scales, (64) “the more assets young people possess, the fewer risk behaviours they engage in – less violence, less problem alcohol and other drug use, less early sexual intercourse, less delinquency.” (p. 113) Internal assets include a commitment to learning, positive value systems, social skills and positive self-identity. External assets include social support from family, adults, school and neighbourhood, empowerment and opportunities for constructive use of time. (62) School-wide programming that focuses on promoting these assets in all the children and youth have been shown to be effective in preventing anxiety and depression; however, these programs need to start early and continue over the long-term. (6, 14, 58)

Moreover, there is evidence that engaged youth are less depressed, have higher self-esteem, are more physically active, obtain higher grades in school and show a greater commitment to their friends, families and communities. Participation on a Healthy School committee provides an opportunity for children and youth to develop responsibility for decision-making and problem-solving, and to get involved in leadership roles and activities that are youth-friendly and encourage youth ownership and participation. The whole student population beneﬁts from student-led activities and projects.

Evidence from systematic reviews and intervention trials on mental health promotion in schools indicates that comprehensive programs that target multiple health outcomes in the context of a Healthy Schools approach are the most effective. (17, 34) These interventions have successfully led to increases in mental well-being, competence, social skills and school achievement, and a reduction in anxiety and depressive symptoms, aggression and bullying. Curricula that develop communication skills, stress management and other life skills increase individual resilience. School-based peer mediation programs, anti-bullying policies and programs and the promotion of cultural sensitivity and inclusiveness all contribute to creating a supportive Healthy Schools. When all of the elements of a Healthy School are operating well, children are more likely to develop resilience and other protective factors for facing life challenges. (58)

In order to prevent mental disorders and reduce the number of children affected, prevention approaches need to address the interaction of multiple risk factors that may lead to, or protective factors that can prevent, mental disorders. (6) In addition to learning mental health skills, individual attention and short-term counselling also contribute to mental health promotion programs. The majority of schools in Ontario have access to social workers, guidance counsellors, youth workers and psychologists. In some cases, service agreements between public health departments, school boards, and community agencies are in place to offer these types of support services in schools. For example, school boards with a signiﬁcant rural population and limited access to health services have PHNs providing counselling services to both elementary and secondary school students.

The school-based health clinic is another model of care for delivering prevention and promotion services to youth. Rural students often have limited access to community services and urban students often have to take time out from classes to attend off-site medical appointments.

Another effective mental health promotion intervention is small group learning, or group discussion. Students who have been identiﬁed by school staff are often referred to these groups. The groups create a circle of peer support through which to learn a variety of skills including communication, reframing negative thoughts, anger management, refusal skills and building healthy relationships, to name a few. This work is particularly valuable because it enables a peer group as a whole to experience a shift in social norms and increase awareness, knowledge and critical-thinking skills. (50)

Mental health should be viewed from the perspective of promoting healthy development as key to preventing mental health problems and addressing barriers to development and learning. This involves developing a wide range of programs that focus on individuals, environmental systems and mental and physical health. Interventions need to not only strengthen individuals but also enhance the nurturing and supportive conditions at school, at home and in the community. (65)

See Appendix D for a Checklist for Planning and Implementing Healthy Schools, which includes the recommended practices discussed in this Guidance Document.

Section 4. Integration with Other Requirements Under OPHS and Other Strategies and Programs

There are references throughout the OPHS to utilizing a comprehensive health promotion approach to inﬂ uence the development of healthy public policy and creation/enhancement of supportive environments. As noted earlier, a comprehensive Healthy Schools approach ensures all of the above; following recommendations in the section above will support a comprehensive school health approach and facilitate implementation of the OPHS in an integrated fashion.

Suggestions about coordinating teams across programs within the health unit, as described in Section 3.b.ii, can facilitate integration, as a team-based approach will enable the implementation of initiatives across the OPHS within a school. In addition, the Healthy Schools approach, described in Section 3.b.vi, includes a process for assessment and planning that provides opportunities to address the needs of schools, which will likely vary and require an integrated approach.

Table 3 summarizes the OPHS Program Standards and requirements that speciﬁcally address populations in educational settings, including elementary, secondary and post-secondary. Additional information can be obtained from A Look at the OPHS and Protocols Across Various Dimensions, which can be retrieved from http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/listings.html

As many of the OPHS include requirements for the school setting, a comprehensive school health approach supported by an internal coordinating structure in a health unit and an assessment and planning processes is recommended.

Table 3: OPHS Standards and Requirements related to Educational Settings
Program Standard	Requirement
Chronic Disease Prevention	3. The board of health shall work with school boards and/or staff of elementary, secondary and post-secondary educational settings, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and the creation or enhancement of supportive environments to address the following topics: Healthy eating; Healthy weights; Comprehensive tobacco control; Physical activity; Alcohol use; and Exposure to ultraviolet radiation. These efforts shall include: a. Assessing the needs of the educational setting; and b. Assisting with the development and/or review of curriculum support. 4. The board of health shall use a comprehensive health promotion approach to increase the capacity of workplaces to develop and implement healthy policies and programs and to create or enhance supportive environments to address the following topics: Healthy eating; Healthy weights; Comprehensive tobacco control; Physical activity; Alcohol use; Work stress; and Exposure to ultraviolet radiation. These efforts shall include: a. Conducting a situational assessment in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current); and b. Reviewing, adapting and/or providing behaviour change support resources and programs.
Chronic Disease Prevention	The board of health shall implement and enforce the Smoke-Free Ontario Act in accordance with provincial protocols, including but not limited to the Tobacco Compliance Protocol, 2008 (or as current). “(…It is recommended that boards of health also offer to develop a written agreement with every school board, covering all local schools and outlining the roles and responsibilities of the board of health and school officials and the procedures related to the Smoke-Free Ontario Act.”) [OPHS Footnote 8]
Prevention of Injury and Substance Misuse	2. The board of health shall work with community partners, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and programs and the creation or enhancement of safe and supportive environments that address the following: Alcohol and other substances; Falls across the lifespan; Road and off-road safety; and Other areas of public health importance for the prevention of injuries as identified by local surveillance in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). Community partners may include but are not limited to … school boards and/or staff, school councils and students of elementary, secondary and post-secondary educational settings…[OPHS Footnote 10] Use an integrated and comprehensive approach to influence the development and implementation of healthy public policy and/or create safe and supportive environments that address… (see topics above). 3. The board of health shall use a comprehensive health promotion* approach to increase the capacity of priority populations to prevent injury and substance misuse by:* Collaborating with and engaging community partners; Mobilizing and promoting access to community resources; Providing skill-building opportunities; and Sharing best practices and evidence for the prevention of injury and substance misuse. 5. The board of health shall use a comprehensive health promotion approach in collaboration with community partners [schools/boards] including enforcement agencies, to increase public awareness of and adoption of behaviours that are in accordance with current legislation related to the prevention of injury and substance misuse in the following areas: Alcohol and other substances; Falls across the lifespan; Road and off-road safety; and Other areas of public health importance for the prevention of injuries as identified by local surveillance in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).
Reproductive Health	2. The board of health shall work with community partners, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and the creation or enhancement of supportive environments to address: Pre-conception health; Healthy pregnancies; and Preparation for parenting. These efforts shall include: a. Conducting a situational assessment* in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current); and* b. Reviewing, adapting and/or providing behaviour change support resources and programs (This could include curriculum support resources (in preschools, schools, etc.) [OPHS Footnote 17]. 4. The board of health shall provide, in collaboration with community partners, prenatal programs, services and supports, which include: a. Consultation, assessment and referral; and b. Group sessions.
Child Health	2. The board of health shall conduct surveillance of children in schools and refer individuals who may be at risk of poor oral health outcomes in accordance with the Oral Health Assessment and Surveillance Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).
	4. The board of health shall work with community partners, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and the creation or enhancement of supportive environments to address: Positive parenting; Breastfeeding; Healthy family dynamics; Healthy eating, healthy weights and physical activity; Growth and development; and Oral health. These efforts shall include: a. Conducting a situational assessment* in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current); and* b. Reviewing, adapting and/or providing behaviour change support resources and programs. (This could include curriculum support resources (in preschools, schools, etc.) workplace support resources etc. [OPHS Footnote 17]
	10. The board of health shall conduct oral screening* in accordance with the Oral Health Assessment and Surveillance Protocol, 2008 (or as current).* (The proposed Oral Health Surveillance Protocol could outline screening processes to be undertaken by boards of health, which may include JK, SK and Grade 2). Where the board of health is denied entry by a school board or school, the board of health shall ensure screening within five working days in alternate facilities.
Sexual Health, Sexually Transmitted Infections, Blood-Borne Infections (including HIV)	5. The board of health shall use a comprehensive health promotion approach to increase the community capacity regarding the promotion of healthy sexuality, including the prevention of adolescent pregnancies, sexually transmitted infections, and blood-borne infections, by: *a. Collaborating with and engaging community partners and priority populations;* b. Mobilizing and promoting access to community resources; c. Providing skill-building opportunities; and d. Sharing best practices and evidence. 6. The board of health shall collaborate with community partners, including school boards, to create supportive environments to promote healthy sexuality and access to sexual health services.
Infectious Diseases Prevention and Control	4. The board of health shall work with community partners to improve public knowledge of infectious diseases of public health importance and infection prevention and control practices in the following areas: Epidemiology of infectious diseases of public health importance that are locally relevant; Respiratory etiquette; Hand hygiene; Vaccinations and medications to prevent or treat infectious diseases of public health importance; Infection prevention and control core competencies, incorporating both Routine Practices (including personal protective equipment) and Additional Precautions (transmission-based precautions); and Other measures, as new interventions and/or disease arise. According to Infectious Diseases Protocol, 2009 14. The board of health shall inspect settings associated with risk of infectious diseases of public health importance in accordance with the …[ ] and the Risk Assessment and Inspection of Facilities Protocol, 2008 (or as current).
Vaccine Preventable Diseases	1. The board of health shall assess, maintain records and report, where applicable, on: The immunization status of children enrolled in licensed child care programs as defined in the Day Nurseries Act; The immunization status of children attending schools in accordance with the Immunization of School Pupils Act; and Immunization administered at board of health-based clinics as required in accordance with the Immunization* Management Protocol, 2008 (or as current).*
	The board of health shall work with community partners* to improve public knowledge and confidence in immunization programs by:* a. Supplementing national and provincial health communications strategies; and/or b. Developing and implementing regional/local communication strategies. Topics to be addressed shall include: The importance of immunization Diseases that vaccines prevent Recommended immunization schedules for children and adults and the importance of adhering to the schedules Introduction of new provincially funded vaccines Promotion of childhood and adult immunization, including high-risk programs The importance of maintaining a personal immunization record for all family members The importance of reporting adverse events following immunization Reporting immunization information to the board of health as required Vaccine safety Legislation related to immunizations
	7. The board of health shall promote and provide provincially funded immunization programs to any eligible person in the health unit, including: Board of health-based clinics; *School-based clinics* (including, but not limited to, hepatitis B and meningococcal immunization); Community-based clinics; and Outreach clinics to priority populations.
	The board of health shall comply with the Immunization Management Protocol 2008, (or as current), that specifies the process for the assessment of the immunization status of children in licensed day nurseries as defined in Day Nurseries Act and the enforcement of the Immunization of School Pupils Act.
Other Opportunities– Emergency Preparedness	5. The board of health shall, in collaboration with community partners,* increase public awareness regarding emergency preparedness activities.*
Food Safety	1. The board of health shall conduct surveillance of: Suspected and confirmed food-borne illnesses; and Food premises in accordance with the Food Safety Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 or as current). 4. The board of health shall ensure food handlers in food premises [school cafeterias, nutrition classes]have access to training in safe food-handling practices and principles in accordance with the Food Safety Protocol, 2008 (or as current). 5. The board of health shall increase public awareness of food-borne illnesses and safe food-handling practices and principles in accordance with the Food Safety Protocol, 2008 (or as current) by: a. Adapting and/or supplementing national and provincial food safety communications strategies; and b. Developing and implementing regional/local communications strategies. 7. The board of health shall inspect food premises and provide all the components of the Food Safety Program within food premises as defined by the Health Protection and Promotion Act and in accordance with the Food Premises Regulation (O. Reg. 562); the Food Safety Protocol, 2008 (or as current); and all other applicable Acts.
Safe Water	2. The board of health shall conduct surveillance of drinking-water systems and of drinking water illnesses of public health importance, their associated risk factors and emerging trends in accordance with the Drinking Water Protocol, 2008 (or as current); the Infectious Diseases Protocol, 2008 (or as current); and the Population Health Assessment and Surveillance Protocol, 2008 (or as current). 10. The board of health shall ensure that the medical officer of health or designate receives reports of and responds to complaints regarding infection prevention and control practices in settings for which no regulatory bodies exist, particularly personal services settings. This shall be done in accordance with the Infection Prevention and Control in Personal Services Settings Protocol, 2008 (or as current) and the Infection Prevention and Control Practices Complaint Protocol, 2008 (or as current).

a) Considerations Regarding the Foundational Standard: Population Health Assessment/Situational Analysis, Surveillance, Research and Knowledge Exchange, Program Evaluation

Population Health/Situational Assessment/Surveillance

As noted in Section 3.b.vi., assessment of school community strengths/needs is an identiﬁed step in a comprehensive Healthy Schools approach. This enables schools to prioritize issues that need to be addressed. Schools can also assess the degree to which comprehensive school health is being implemented at the school level.

Situational assessment is particularly valuable when questions of equity arise because stafﬁng does not permit a program or service to be offered to all schools. Possible considerations for making such decisions are theoretical models, such as the Stages of Change (i.e., readiness of the school to take action) and consideration of the school community’s knowledge of and support for a comprehensive approach. Decisions about whether to provide speciﬁ c services (e.g., one-time presentations) should be considered in light of available evidence of effectiveness and in the context of using a comprehensive approach, whenever possible.

Section 5 includes links to a range of recommended assessment resources. Sources of data and information to identify schools with greatest need or to identify priority issues in schools or school boards include:

Dental data (e.g., Ontario Health Information Support System, OHISS)
Early Development Instrument (EDI) data on kindergarten students upon school entry (http://www.offordcentre.com/readiness/EDI_viewonly.html)
Safe Schools/bullying surveys conducted by school boards
School Council surveys
School Health Environment Survey completed by schools in 2007/08
School Health Proﬁle tool completed with healthy school committee
Focus groups or surveys of school stakeholder groups (students, parents, staff, etc.)
School use of the JCSH Healthy School Planner (http://www.jcsh-cces.ca/)
YOO Magazine online School Surveys from The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO and the IWK Health Centre (www.yoomagazine.net)
Meetings with principals and other key contacts
People for Education annual survey (http://www.peopleforeducation.com/school_survey)
Ontario Student Drug Use and Health Survey (OSDUHS) from Centre for Addiction and Mental Health (CAMH) (http://www.camh.net/Research/osdus.html)
Nutrition data of pre-school population, i.e., NutriStep (http://www.nutristep.ca/).

Research

Before research is undertaken in a school setting, PHUs should consider how this research will support the overall mandate of public health or the school board. Health units should communicate with school board partners early on to ensure that research proposals are of mutual interest. Boards of education may have an independent research ethics approval process, which often requires adequate lead time for School Board approval. If pursuing research in a school setting, PHUs should also consider what summary ﬁndings/reports can be returned to school/school board participants and how PHUs can work with schools/school boards and community partners to act upon the research ﬁndings, as appropriate.

Knowledge Exchange

The Healthy Schools process described in this document offers opportunity for knowledge exchange at various levels, e.g., at the level of a school, school board and within and across health units. As public health practitioners work with schools, an opportunity exists to communicate and utilize available assessment and surveillance data to inform action at the school level. The celebration phase of a Healthy Schools approach also presents an excellent opportunity for knowledge exchange, in particular to celebrate success at the school level that can inform future practice. Results and successes can be communicated board-wide, within the particular health unit, and across health units, in order to disseminate information on trends and effective practices. Schools and school boards may also provide knowledge exchange opportunities that would enhance the practice of public health staff.

Program Evaluation

The Foundational Standard also discusses using quantitative, qualitative and mixed-method approaches to conduct process and outcome evaluations of programs and services being offered, to assist decision-making. Data generated would determine the effectiveness of existing programs and services and support the establishment of new ones.

Other Considerations

An overall framework for how the health unit works with schools is helpful in making decisions about stafﬁng, approach, etc. An integrated approach would see the entire health unit embracing Healthy Schools and developing a structure that facilitates this work, with linkages to speciﬁc programs and services that are also planned and delivered using a comprehensive approach.

b) Integration with Inter-sectoral Strategies and Programs

As mentioned throughout the document, a Healthy Schools approach recognizes opportunities for alignment of public health efforts with the education sector’s priority strategies and initiatives. The Ontario Ministry of Education’s list of education-related topics can be found at http://www.edu.gov.on.ca/eng/popularTopics.html. Communications to school boards via Ministry of Education Policy and Program Memoranda can be found at http://cal2.edu.gov.on.ca/. Initiatives that are worth noting include:

Parent Involvement: The Ministry of Education is invested in engaging parents in the educational experiences of their children. Parents Reaching Out grants are designed to encourage parents’ involvement in their children’s education and to support student learning at the school, regional and provincial levels. School-based funding must be applied for by the school council and school councils are encouraged to work with schools and their school board’s Parent Involvement Committee to identify potential project opportunities. This is an excellent opportunity to introduce health-related programming. See http://www.edu.gov.on.ca/eng/parents/reaching.html for more information.
Character Development: The goal of the Character Development initiative is to develop school environments where all people – students, teachers, administrators and support staff – treat each other with care and respect. This initiative is based on four essential components: academic achievement, character development, citizenship development and respect for diversity. These components resonate with youth development principles and approaches that have been effective in helping youth develop positive health behaviours and reduce risk behaviours. This initiative also directs schools to seek out alliances among parents and community partners to support learning in all forms and settings. See http://www.edu.gov.on.ca/eng/literacynumeracy/character.html for more information.
Safe Schools: The Government of Ontario is committed to providing a safe and secure environment for learning. The Safe Schools Act came into effect in 2000 (see http://www.edu.gov.on.ca/safeschl/eng/ssa.html). In 2004, a Safe Schools Action Team was instituted to conduct a review of the Act. Their 2006 report led to Bill 212 on Progressive Discipline and School Safety in 2007. The Safe Schools Action Team also produced a report in 2008 with recommendations on addressing gender-based violence, homophobia, sexual harassment and inappropriate sexual behaviour – Shaping a Culture of Respect in Our Schools: Promoting Safe and Healthy Relationships. On Feb 1, 2010 the Keeping Our Kids Safe at School Act (2009) came into effect, which includes requirements for reporting and responding to incidents that could lead to suspension or expulsion. See http://www.edu.gov.on.ca/eng/parents/safeschools.html for a complete listing of Safe Schools information. The related 2009 Policy and Program Memorandum 144 (http://www.edu.gov.on.ca/extra/eng/ppm/144.html) makes reference to Safe Schools Teams and states, “Each school must have in place a Safe Schools Team responsible for school safety that is composed of at least one student (where appropriate), one parent, one teacher, one non-teaching staff member, one community partner, and the principal. An existing school committee (e.g., the Healthy Schools committee) can assume this role. The chair of this team must be a staff member.” Policy and Program Memorandum 145 (http://www.edu.gov.on.ca/extra/eng/ppm/145.html) includes mention of potential roles for public health and other community agencies in relation to prevention and intervention (e.g., staff training, student and parent support, and youth leadership).
Student Support Leadership Initiative: The Student Support Leadership Initiative was developed by the Ministries of Education and Children and Youth Services and launched in the 2007/08 school year. This initiative supports and is aligned with Ontario’s Safe Schools Strategy, recommendations of the Working Table on Special Education and Ontario’s ﬁrst policy framework for child and youth mental health, entitled A Shared Responsibility: Ontario’s Policy Framework for Child and Youth Mental Health (2006). (51) The Student Support Leadership initiative was developed in response to recent changes to the safe schools provisions of the Education Act and related Policy/Program Memoranda that came into effect February 1, 2008. School boards are being encouraged to form partnerships with community agencies, including public health, to provide non-academic supports that promote positive student behaviour and support the healthy development of Ontario’s children and youth. The local geographic cluster partnerships are intended to better meet the needs of students through collaborative planning, coordination and referrals. See http://cal2.edu.gov.on.ca/feb2008/studentSupport.pdf for more information.
Student Voice is a student engagement initiative of the Ministry of Education to hear from students about what they want from the education experience. The Student Voice initiative sponsors student-led projects, which can include projects to promote health. Public health may help students formulate project ideas and implement their plans. For more information visit http://www.edu.gov.on.ca/eng/students/speakup/index.html.
Roots of Youth Violence: The Roots of Youth Violence review was conducted by the Ontario Government to help identify what contributes to youth violence and to provide recommendations to continue building safer, stronger communities. The government asked that the review build on existing investments in Ontario’s public education system and on the important work of previous reviews and key partners, including the City of Toronto and the United Way, in creating opportunities for young people and in making schools and communities safer. The government also asked the review to consider existing provincial investments and programs related to child development, youth violence and youth at risk, and creating educational and employment opportunities for young people. The review report provides valuable input about what youth need. See http://www.rootsofyouthviolence.on.ca/english/index.asp.
Ontario’s After-School Initiative: The Ministry of Health Promotion has developed the Child and Youth Health and Wellness (After-School) Strategy to provide children and youth in targeted priority areas in Ontario with access to safe, active and healthy after-school activities. It is a key initiative in the government’s Poverty Reduction Strategy and takes an integrated approach to address multiple risk factors affecting the health and well-being of children and youth. Programming proposals for children and youth in grades 1–12 can focus on physical activity, healthy eating and nutrition and wellness and personal health education, as well as local programming needs, such as youth employment, homework help, cultural and arts activities and knowledge of community resources and how to access them. See http://www.mhp.gov.on.ca/english/after_school/default.asp.
The revised Ontario Health and Physical Education Curriculum: In September 2007, the Ministry of Education began a review of the Ontario Health and Physical Education Curriculum for both elementary and secondary schools. Extensive consultation occurred throughout the province and the revised curriculum documents were released in January 2010. Beginning in September 2010, all health and physical education programs for Grades 1 to 8 will be based on the expectations outlined in this document. The curriculum can be found at http://www.edu.gov.on.ca/eng/curriculum/elementary/health18curr2010.pdf.
Healthy Schools Recognition Program: In December 2006, the Government of Ontario launched Ontario’s Healthy Schools Recognition Program to promote and celebrate healthy behaviours and practices in Ontario’s schools. Schools pledge to take on a healthy activity in their school and receive recognition for it. Schools can start a new activity or build on an existing one. Activities are to be consistent with the Foundations for a Healthy School framework, which encourages a comprehensive health promotion approach. Public health is identiﬁed as a key community partner. Participating schools receive a certiﬁcate and pennant and are posted on the Ministry of Education’s website. The Ministry of Education and Ministry of Health Promotion both support this program. See http://www.edu.gov.on.ca/eng/healthyschools/challenge.html for details and tools.
School Food and Beverage Policy: In January 2010, Ontario introduced a School Food and Beverage policy (PPM 150) that will ensure that healthy food and beverages are sold in schools. The policy will apply to food and beverages sold in all venues on school property, such as cafeterias, vending machines and tuck shops; through all programs, including catered lunch programs; and at all events on school property, including bake sales and sport events. The nutrition standards will apply to all food and beverages sold at schools. They will not apply to lunches or snacks that are brought from home. For more information see http://www.edu.gov.on.ca/eng/healthyschools/policy.html.

Section 5. Resources to Support Implementation

Table 4: Resources to Support Implementation
Organization and description	Name of resource	Type of resource	Description	Link
International
International Union for Health Promotion and Education	Achieving Health Promoting Schools: Guidelines for Promoting Health in Schools	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	International guidelines for promoting health in schools.	http://www.iuhpe.org/uploaded/Publications/Books_Reports/HPS_GuidelinesII_2009_English.pdf
World Health Organization Global School Health Initiative School and Youth Health	WHO School Health Information Series and Expert Committee Reports	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	A variety of documents in English and French developed by and for WHO to strengthen international, national and local efforts that increase support for school and youth-focused prevention programmes. They also provide advocates with guidance about specific actions that can be taken to improve such programmes.	http://www.who.int/school_youth_health/en/ http://www.who.int/school_youth_health/resources/en/
U.K. Government – Department of Education and Skills	National Healthy School Standard - A Toolkit for Local Coordinat-ors	X Knowledge ¨ Network ¨ Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	A toolkit designed to assist local coordinators in achieving the target of the national program.
U.S. Center for Disease Control Coordinated School Health	Various	X Knowledge ¨ Network X Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	A portal to various tools promoted by the CDC for Coordinated School Health, including guidelines to address various health topics in schools.	http://www.cdc.gov/HealthyYouth/
Search Institute Minneapolis, Minnesota, USA	Develop-mental Assets Tools	X Knowledge X Network X Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	Forty common sense, positive experiences, relationships and qualities that influence choices young people make and help them become caring responsible adults. Additional resources for training and implementation can be found on this site.	http://www.search-institute.org
Queensland (Australia) Health	Health Promoting Schools Toolbox	X Knowledge ¨ Network X Assessment tool ¨ Technical assistance/ training ¨ Not specified/ Organizational	Ten toolkits for schools to help them understand, plan and implement a Healthy Schools approach.	http://www.health.qld.gov.au/healthyschools/toolbox.asp
National
Joint Consortium for School Health The JCSH serves to support its member governments by providing a forum, tools and resources for keeping up-to-date on latest approaches to comprehensive school health in Canada and around the world.	Healthy School Planner	¨ Knowledge ¨ Network X Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	The JCSH Healthy School Planner is an online tool designed to help Canadian schools create healthier environments. It offers individual schools a way to assess the overall state of their environment, as well as the choice to zero in on one or more specific topics, such as healthy eating, physical activity or tobacco.	http://www.jcsh-cces.ca/index.php?option=com_content&view=article&id=54&Itemid=80
	Tool kits	X Knowledge ¨ Network ¨Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Evidence-based resources that set out the strategies most effective to address a variety of health topics in schools. Health topics include: - Substance abuse - Physical activity	www.jcsh-cces.ca (access from left hand side of main page)
	Newsletters	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational		www.jcsh-cces.ca (access from left hand side of main page)
PHE Canada Physical and Health Education Canada (PHE Canada) is a national, charitable, voluntary-sector organization whose primary concern is to influence the healthy development of children and youth by advocating for quality, school-based physical and health education.	Quality School Health Checklist	¨ Knowledge ¨ Network X Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	A checklist to help schools assess if they’re on the right track for Quality School Health.	http://www.phecanada.ca/programs/physical-literacy/physical-literacy-checklist
Public Health Agency of Canada / Health Canada	Description of Compre-hensive School Health	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Describes the comprehensive school health model and its components.	http://www.phac-aspc.gc.ca/dca-dea/7-18yrs-ans/comphealth-eng.php
Public Health Agency of Canada / Health Canada	Health Behaviour of School-Aged Children Survey and Reports	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Information about the Health Behaviour of School-Aged Children Survey and Reports on youth health.	http://www.phac-aspc.gc.ca/dca-dea/7-18yrs-ans/index-eng.php
Canadian School Health Knowledge Network The Canadian School Health Knowledge Network has been formed to help Canadian practitioners, researchers and policy-makers be better informed about the many comprehensive school health programs and initiatives across the country.	Website	¨ Knowledge X Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	These web pages provide an overview and connection point to events, activities, trends, networks, issues and organizations.	http://www.canadianschoolhealth.ca
	Com-munities of practice	¨ Knowledge X Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	The Canadian School Health Knowledge Network is initiating and facilitating several Communities of Practice (CoPs) using new web-based collaboration tools, telephone calls and annual symposia to share information and knowledge among practitioners, experts, government officials, policy-makers and non-governmental organizations.	http://www.safehealthyschools.org/communitiesofpracticeintro.htm
health-evidence.ca	Website	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	This website provides quality research evidence by searching, screening and rating the systematic review evidence and compiling it in a free, searchable online registry. Users can search using topic or setting, as well as other criteria.	http://www.health-evidence.ca/
Canadian Association for School Health	Consensus Statement on Comprehen-sive School Health	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	A consensus statement describing an approach for Comprehensive School Health endorsed by a number of national and provincial NGOs (2007).	http://www.safehealthyschools.org/CSH_Consensus_Statement2007.pdf
Propel Centre for Population Health Impact – University of Waterloo	School Health Action Planning and Evaluation System (SHAPES)	¨ Knowledge ¨ Network X Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	SHAPES generates health profiles of schools, using standard core items. SHAPES is being used for planning, evaluation, surveillance and research across Canada.	http://www.shapes.uwaterloo.ca
Thrive: The Canadian Centre for Positive Youth Development	Various English and French resources on develop-mental assets	X Knowledge X Network X Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	Thrive is dedicated to fostering positive youth development by producing and disseminating effective tools to empower and unite caring adults in all aspects of young people’s lives.	http://www.thrivecanada.ca
Resiliency Initiatives Canada	Resiliency assessment/evaluation protocol Resiliency for life workshops Consulta-tion, support and training services	X Knowledge X Network X Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	Protocol provides the basis for early identification and development of short-term and long-term action plans for youth, and for evaluating effectiveness of interventions.	http://www.resiliencyinitiatives.ca
Centres of Excellence for Children’s Wellbeing: Youth Engagement	Youth Engagement Framework What is youth engage-ment? Let Discussion Guide Us	X Knowledge X Network X Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	Print resources on how to effectively engage children and youth.	http://www.engagementcentre.ca
Provincial
Ontario Ministry of Education	Healthy Schools Information for Principals and Teachers	X Knowledge ¨ Network X Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	A variety of tools that teachers and principals can use to learn more about what makes a school healthy, assess what their school is doing and do their part to make their school even healthier.	http://www.edu.gov.on.ca/eng/healthyschools/infoTPA.html
	Ministry of Education’s Policy and Program Memoranda	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Links to memos sent out by the Ministry of Education about various initiatives.	http://cal2.edu.gov.on.ca/
Ontario Healthy Schools Coalition The Ontario Healthy Schools Coalition is an Ontario-wide, broad-based coalition, with members from public health units, school boards, hospitals, mental health agencies, universities, health-related organizations, education-related organizations and parent and student organizations.	OHSC Telecon-ferences Ontario School Health Initiatives Database (under develop-ment)	¨ Knowledge X Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	A quarterly teleconference to share information about provincial Healthy Schools activities. A database of Healthy School initiatives and other health-related school programming from across Ontario.	http://www.opha.on.ca/our_voice/collaborations/ohsc.shtml http://www.opha.on.ca/resources/topics/h.shtml#schools http://opha.on.ca/databases/schoolhealth/index.php
Ophea Ophea is a not-for-profit organization dedicated to supporting schools and communities through quality program supports, partnerships and advocacy.	Ophea offers a number of resources and programs that support school health. Ophea’s website includes a Healthy Schools and Healthy Commun-ities section that includes information and resources to support public health profession-als in their work in schools.	X Knowledge X Network ¨ Assessment tool X Technical assistance/ training ¨ Not specified/ organizational	Ophea provides quality programs, services and training to schools and communities to enable children and youth to lead healthy, active lives. Ophea’s programs and services can help school communities implement the health and physical education curriculum, daily physical activity and a variety of health-related topics that address all the components of the Foundations for a Healthy School framework.	http://ophea.net/ http://www.ophea.net/healthy-schools-communities http://www.ophea.net/dpa2009
Public Health Research Education and Development PHRED contributes to health promotion and protection, and the prevention of health problems, by conducting applied research relevant to public health practice.		X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/training ¨ Not specified/ organizational	The PHRED website provides access to reports, including some that are relevant for school-based initiatives.	http://www.phred-redsp.on.ca/
Provinces Outside Ontario
Newfoundland and Labrador Healthy Students Healthy Schools	Various	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	The website contains information about new and ongoing programs focusing on healthy eating, active living and living smoke-free, including resources and links to information and education tools.	http://www.livinghealthyschools.com/livinghealth_overview.html
New Brunswick Healthy Schools – Wellness Strategy	Various in English and French	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Information about Wellness Strategy initiatives in New Brunswick schools.	http://www.gnb.ca/0131/wellness_Sch-e.asp
Manitoba Healthy Schools This initiative in Manitoba uses a Healthy Schools framework to focus on six important health issues, using comprehensive school health principles.	Various in English and French	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Information about Healthy Schools initiatives in Manitoba, including information about what’s happening around the province and knowledge resources for schools, parents, youth and kids.	http://www.gov.mb.ca/healthyschools/index.html
Saskatchewan School PLUS School PLUS is a province-wide initiative led by the Ministry of Education and the provincial education system that promotes learning success and well-being for every child and young person.	Various	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	Information about the School PLUS initiative, including relevant reports and learning guides.	http://www.education.gov.sk.ca/SchoolPLUS
Alberta Healthy U	Various	X Knowledge ¨ Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	The website includes a number of sections with information and ideas about how parents, kids and school staff are making sure that Alberta kids get a healthy and active start in life.	http://www.healthyalberta.com/HealthyPlaces/282.htm
British Columbia Healthy Schools	Various	X Knowledge X Network ¨ Assessment tool ¨ Technical assistance/ training ¨ Not specified/ organizational	The website provides information about Healthy Schools initiatives in B.C., with links to tools and resources.	http://www.bced.gov.bc.ca/health/welcome.htm

Knowledge tool: refers to definitions, program models, information for different audiences, program reports, public research, etc.
Network: refers to a formalized network which could accommodate Ontario participation.
Assessment tool: refers to a specific tool(s) to complete an assessment of school-based healthy school activities.
Technical assistance/training: refers to expert instruction or training to support uptake of a tool, process or program.

Note: while speciﬁc tools and resources are referenced below, many of the listed organizations offer a more exhaustive group of resources that can be accessed through their websites.

Section 6. Conclusion

This Guidance Document is one of a series that have been prepared by the Ontario Ministry of Health Promotion to provide guidance to boards of health as they implement health promotion programs and services that fall under the 2008 Ontario Public Health Standards (OPHS). This Guidance Document has provided background information speciﬁc to school health, including its signiﬁcance and burden.

In addition, this Guidance Document has suggested strategies for consideration, and examined evidence and rationale for a comprehensive school health approach that is relevant for all requirements pertaining to schools as a setting.

Achieving overall health goals and societal outcomes will depend on the efforts of boards of health working together with many other community partners including schools and also non-governmental organizations, local and municipal governments, government funded agencies and the private sector. By working in partnership towards a common set of requirements, Ontario can better accomplish its health goals by reaching for higher standards and adequately measuring the processes involved.

The health of individuals and communities in Ontario is signiﬁ cantly inﬂuenced by complex interactions between social and economic factors, the physical environment and individual behaviours and conditions. Addressing the determinants of health and reducing health inequities will also ensure that boards of health are successful in their efforts.

Acronyms

CHP – Comprehensive Health Promotion

DPA – Daily Physical Activity HPS – Health Promoting School

HBSC – Healthy Behaviour in School-aged Children (study)

JCSH – Joint Consortium for School Health

MOH – Medical Officer of Health OHSC – Ontario Healthy Schools Coalition

OPHEA – Ontario Physical and Health Education Association

OPHS – Ontario Public Health Standards

PHU – Public Health Unit

PHN – Public Health Nurse

WHO – World Health Organization

Appendix A

Appendix A: What is a Health Promoting School?

What is a Health Promoting School?

A health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning and working. (World Health Organization http://www.who.int/school_youth_health/gshi/hps/en/print.html)

Vision Statement for Health Promoting Schools in Australia

A Health Promoting School strives to nurture the social, emotional, physical and spiritual well-being, and cognitive development of its students, staff and community. (Australian Health Promoting Schools Association http://www.ahpsa.org.au/pages/about.php)

Comprehensive School Health

Comprehensive school health is an internationally recognized framework for supporting improvements in students’ educational outcomes, while addressing school health in a planned, integrated and holistic way. It is not just about what happens in the classroom, but rather encompasses the whole school environment, with actions addressing four distinct but interrelated pillars that provide a strong foundation for comprehensive school health:

Social and physical environment;
Teaching and learning;
Healthy school policy; and
Partnerships and services.

When actions in all four pillars are harmonized, students are supported to realize their full potential as learners – and as healthy, productive members of society. (Joint Consortium for School Health http://eng.jcsh-cces.ca/upload/JCSH%20CSH%20Framework%20FINAL%20Nov%2008.pdf)

Comprehensive School Health, also known as “health promoting schools” in some regions, refers to a multifaceted approach that includes teaching health knowledge and skills in the classroom, creating health-enabling social and physical environments and facilitating links with parents, local agencies and the wider community to support optimal health and learning (2, 4). (Canadian Association for School Health http://www.safehealthyschools.org/CSH_Consensus_Statement2007.pdf)

Foundations for a Healthy School

Generally, a healthy school has:

High quality instruction and programs;
A healthy physical environment;
A supportive social environment; and
Community partnerships.

Within this broad foundation, a variety of health-related topics need to be considered, including:

Healthy eating
Substance use and abuse
Physical activity
Healthy growth and development
Bullying prevention
Personal safety and injury prevention
Mental health

(Healthy Schools Recognition Program http://www.edu.gov.on.ca/eng/healthyschools/foundations.pdf)

Appendix B

Appendix B: The A, B, Cs of Healthy Schools

A: Establish a Healthy School Committee

Schools need a structure through which Healthy Schools work is coordinated – it shouldn’t be just one person in the school. The Healthy School Committee should involve students, parents, teachers, principal/vice principal, public health and other community partners. In secondary schools, this group may primarily consist of students, a teacher advisor, and public health representative. Student involvement and leadership in all aspects of the planning process described below is essential. The Healthy School Committee may also be called Health Action Team; Safe, Healthy and Caring School Committee; or School Improvement Committee. It may be a sub-committee of School Council or any other conﬁguration that suits the individual school.

B: Engage in a Healthy Schools Planning Process

Schools need to engage all school stakeholders in the process of:

Creating a shared vision of their school as a Healthy School;
Assessing existing strengths and needs;
Prioritizing an issue;
Developing a comprehensive plan (see C);
Implementing the plan;
Monitoring/evaluating; and
Celebrating and communicating successes.

C: Ensure the School’s Plan is Comprehensive

Schools need to use the Foundations for a Healthy School Framework and endeavour to include activities within each of the four framework components in the school’s plan. This will ensure a comprehensive plan that is more likely to result in substantial and sustainable improvements.

High Quality Instruction and Programs
Supportive Social Environment
Healthy Physical Environment
Community Partnerships (to enhance access to resources and services)

Note that healthy school policies are embedded within each of these four components.

Appendix C

Appendix C: Lessons Learned from Around the World Re: Healthy Schools

The U.S. Department of Health and Human Services, Centers for Disease Control released a report in 2003 entitled Stories from the Field: Lessons Learned About Building Coordinated School Health Programs. It describes district and school-level teams and the concept using nine case examples. Ten key lessons are shared:

The support of district and building-level leadership is essential.
Policies reinforce district and school commitment to positive student academic and health outcomes.
Outside organizations must be involved with schools.
Parents, families and caretakers are essential partners.
Students are significant contributors to the success of programs, as well as program beneficiaries.
The coordinated school health program is a clear, practical approach.
Successful programs must offer opportunities for participants to interact with their colleagues.
Professional development engages staff members and sustains their participation.
Changing a system takes time.
Data make the case for a coordinated school health program.

Lawrence St. Leger (14) presents similar lessons learned from around the world about what works in implementing Health Promoting Schools:

Developing and maintaining a democratic and participatory school community.
Developing partnerships between education and health sector policy-makers.
Ensuring students and parents feel they have some sense of ownership in the life of the school.
Implementing a diversity of learning and teaching strategies.
Providing adequate time for class-based activities, organisation and coordination, and out-of-class activities.
Exploring health issues within the context of the students’ lives and community.
Utilising strategies that adopt a whole school approach rather than primarily a classroom-learning approach.
Providing ongoing capacity-building opportunities for teachers and associated staff.
Creating an excellent social environment which fosters open and honest relationships within the school community.
Ensuring a consistency of approach across the school and between the school, home and wider community.
Developing both a sense of direction in the goals of the school and clear and unambiguous leadership and administrative support.
Providing resources that complement the fundamental role of the teacher and which are of a sound theoretical and accurate factual base.
Creating a climate where there are high expectations of students in their social interactions and educational attainments.

(From: Achieving Health Promoting Schools: Guidelines for Promoting Health in Schools, IUHPE)

Lessons Learned from Vince Whitman, C. and Aldinger, C.E.(Eds.). (2009). Case Studies in Global School Health Promotion: From Research to Practice. New York: Springer
Vince Whitman presents a framework of 12 major factors that impact the effectiveness of the process of implementing the Health-Promoting School concept, The Wheel of Factors Inﬂuencing Implementation of Policy and Practice. The above editors collected and conducted qualitative analysis of 26 case studies on school health promotion from around the world. Coding resulted in the following ranking of the factors (see reference p. 38):

Vision and concept/international and national guidelines
Dedicated time and resources (financial, human, technical and material)
Stakeholder ownership and participation
Team training and ongoing coaching/learning community
Cross-sector collaboration
Champions and leaders at all levels
Data-driven planning and decision making
Administrative and management support
Adapting to local concerns
Attention to external forces
Critical mass and supportive norms
Stage of readiness

Appendix D

Appendix D: Checklist for Planning and Implementing Healthy Schools

This checklist is a summary of the main points for consideration by public health units as they undertake Healthy Schools work. It is intended to help health unit staff in their efforts to support schools within a comprehensive health promotion approach.

Strengths-based Approach (Ref. SHGD 3.b.i)

We acknowledge that developing positive working relationships with all school stakeholders (children/youth, parents, school and board staff) and other community partners is key to Healthy Schools success.
We recognize that coordinating structures (e.g., committees, action teams) at multiple levels are key to enabling meaningful and sustainable action planning.
We consider the school as a setting to not only promote the health of children and youth, but parents and school staff as well.
We meaningfully involve youth in planning and implementation, whether at health unit, school board, school or community levels.
We utilize a strengths-based approach in our work with children and youth, parents, schools and communities (e.g., note and build upon their strengths instead of focusing on deficits).
We tailor our public health programs and services to meet local population health needs.
We recognize that comprehensive health promotion work with school settings requires long-term commitment and will evolve over time.

Internal Coordination (Ref. SHGD 3.b.ii)

We secure senior and middle management support within the health unit for Healthy Schools.
We have an internal coordinating committee involving representatives from all main departments or programs that work with schools, to increase our effectiveness and efficiency with schools.
We have a way to determine priority of schools for more in-depth health promotion service (e.g., schools at a point of readiness, highest need schools, school boards’ priority schools).
We assign health unit staff in a liaison capacity to work with prioritized schools.
We have health unit staff with issue-specific expertise that can support schools with issue-specific planning.
We (whether liaison or program-specific staff) provide advice and information to link children/youth, parents and school staff to community programs and services in relation to various health issues.
We ensure that staff understand and value the policies, procedures, processes and structures of the school board and individual schools.

External Coordination (Ref. SHGD 3.b.iii)

We have annual meetings of directors/Medical Ofﬁcer of Health and managers/superintendents of our local school boards and the health unit to develop positive working relationships and commitment to working together
We secure support for Healthy Schools (may include policy work) from superintendents and other individuals with school board responsibilities related to student health.
We explore, with school boards, how best to integrate Healthy Schools into their school board and school-level strategic planning and/or initiatives (e.g., school improvement planning, safe schools, character education, youth leadership, Student Success, parent engagement, environmental education).
We encourage each school board and participating school to identify a “point person”/main contact for Healthy Schools with whom public health staff can connect.
We provide school boards and schools with the name of our health unit “point person” or primary coordinator(s) for Healthy Schools, and/or list of appropriate contacts in our various departments.
We have a school board(s)-health unit coordinating committee for our local Healthy School initiative (may include other community partners or be a community-wide coordinating committee).
Where several health units work with single school boards, we ensure coordination amongst the health units.

School-Level Coordination (Ref. SHGD 3.b.iv)

We understand that an ideal coordinating committee at an elementary school level would include representatives from school administration, school staff, students, parents and relevant community partners, such as public health, recreation and police.
We understand that a coordinating committee at a secondary school level might primarily include students and a teacher/advisor, with support from school administration, parents, and relevant community partners (such as public health, recreation, police), as appropriate.
We provide the school with the name of a “point person” or primary coordinator(s) for Healthy Schools.

Implementing a Comprehensive Health Promotion Approach (Ref. SHGD 3.b.v-vi)

We ensure a common understanding of Healthy Schools that includes a comprehensive plan for health action addressing four components, with policies embedded within each:

High Quality Instruction and Programs
A Healthy Physical Environment
A Supportive Social Environment
Community Partnerships

In collaboration with school boards and/or schools:

We plan processes to assess the strengths and needs of the school population to inform planning and program and policy development.
We assist with recommending, developing and/or reviewing curriculum supports to enhance implementation of the Health and Physical Education and other related curricula.
We endeavour to raise awareness and build skills of all school stakeholders (children/youth, parents, staff) in relation to various health issues.
We seek opportunities to create or enhance the physical environments of schools to be more health-supporting.
We seek opportunities to create or enhance the social environments of schools to be more health-supporting.
We seek opportunities to develop partnerships and promote access to community resources, including programs and services.
We work on health promoting policies, whether a general Healthy School policy or issue-speciﬁ c policy.
We prepare the necessary tools that schools will need to move forward with Healthy Schools, such as:
- Tips on mobilizing a Health Action Team or integrating with an existing working group
- Visioning questions/process
- Agreement/statement of commitment
- Assessment of school strengths and needs to assist in prioritizing issue(s)
- Planning template
- Activity report
- Final year-end report/ monitoring/evaluating tool
- Minutes form
- Recognition and communication options (e.g., banners, plaques, newsletter item, media coverage)
We plan for capacity-building with relevant stakeholders regarding the Healthy Schools process and their respective roles, such as:
- Principals/vice-principals
- Teachers/education staff
- Children/youth
- Parents
- Community partners, e.g. recreation, police, our own public health staff, etc.
- We plan networking/sharing/celebration opportunities.
- We identify funding opportunities to support/stimulate Healthy Schools work.
We plan networking/sharing/celebration opportunities.
We identify funding opportunities to support/stimulate Healthy Schools work.

Communications (Ref. SHGD 3.b.vii)

We connect with our school board partners to understand the necessary process for relaying health-related messages to principals, teachers, parents and students.
We coordinate our communications to school boards/schools to ensure they do not feel bombarded from numerous departments, and that necessary board-level approval/endorsement of messages is in place.
We adapt and/or supplement national and provincial health communications strategies, and/or develop and implement regional/local communications strategies in relation to various health issues.
We track public health supports offered to schools during the school year and provide a summary report to school boards.
We communicate health-related information/Healthy Schools successes/public health school activities to school board personnel, school personnel, parents, students and community, via newsletters or other appropriate means.
We communicate Core Services that are either available to all schools or that members of the public can access through public health (e.g., infectious diseases prevention and control; immunization; cafeteria inspections; drinking water testing; oral health; Smoke-Free Ontario Act enforcement; sexual health services/support; fact sheets/guidelines; newsletter articles; telephone information lines for consultation; health unit website and web-based resources; etc.).
We communicate Elective Services for which, due to resource limitations, not all requests can be met (e.g., Healthy School Committee support; support/small group programs; youth leadership programs; Food Safety Course; travel health clinics; prenatal, breastfeeding, parenting, child/family health and smoking cessation programs; curriculum support/continuing education for teachers; one-on-one consultation and referral).
We assess, consider and implement action on the determinants of health that impact our local population.
We collaborate with relevant partners on efforts that will contribute to children/youth staying in school, as education/literacy is a signiﬁcant determinant of health.
We collaborate with relevant partners on prevention, health promotion, and early identiﬁcation and referral efforts for a wide range of health issues, as overall health is a signiﬁcant factor affecting ability to learn.
We promote positive parenting, healthy family dynamics and healthy growth and development, as these contribute to healthy child and youth development as a determinant of health.
We respect language requirements of French First Language Schools according to French Language Services Act and school board policies.

Mental Health (Ref. SHGD 3.d)

We endeavour to promote not only the physical health but also the mental, emotional and social health and well-being of children, youth, parents and school staff.
We acknowledge that mental health problems and mental illness are risk factors for many health-damaging behaviours, and work with community partners to promote mental well-being and reduce the stress of children/ youth, parents and school staff.
We collaborate with community partners to build protective factors and strengthen the resilience of children/ youth, parents and school staff.

Monitoring/Evaluation

We access, collect and analyze surveillance data on the strengths and health issues of the school-aged population.
We share information related to trends and priority populations with community partners, including school boards and schools.
We share best practices and evidence related to health promotion and disease prevention with relevant stakeholders to support program planning.
We build relationships with community researchers, academic partners and other appropriate organizations to support public health research and knowledge exchange.
We endeavour to collect process and outcome evaluation data on programs and services that are carried out.

Note that “We” refers to the public health unit/department.

Note that “Parents” is used generically to refer to parents/guardians/caregivers.

Note that “Health Action Team” refers to any local school planning group that addresses issues affecting the health (physical, mental, emotional, social, spiritual) of students, staff and/or families. It may have any name, e.g., school health committee; safe, healthy and caring school committee; school improvement team; School Council Health sub-committee; etc.

Note that “Determinants of Health” include the following: Income and social status; Social support networks; Education and literacy; Employment/working conditions; Social and physical environments; Personal health practices and coping skills; Healthy child development; Biology and genetic endowment; Health services; Gender; Culture; and Language.

Note that “Protective Factors” are individual or environmental characteristics, conditions, or behaviours that reduce the effects of stressful life events; increase an individual’s ability to avoid risks or hazards; and promote social and emotional competence to thrive in all aspects of life now and in the future (1). Internal assets are the positive factors that reside inside the individual, such as social competence, coping skills and self-efﬁ cacy. External assets or factors are resources that exist in the individual’s social environment and include parental support, adult mentoring, peer relationships and community organizations (2).

(1) Centers for Disease Control and Prevention. School Connectedness: Strategies for increasing protective factors among youth. Atlanta GA: US Department of Health & Human Services; 2009. Retrieved from: http://www.cdc.gov/healthyyouth/adolescenthealth/connectedness.htm

(2) Fergus S, Zimmerman M. Adolescent Resilience: A framework for understanding health development in the face of risk. Annu Rev. Public Health 2005; 26: 399-419.

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