Can the concept of Health Promoting Schools help to improve students' health knowledge and practices to combat the challenge of communicable diseases: Case study in Hong Kong?

Health behaviours are strongly determined by the different social, economic and environmental circumstances of individuals and populations. Improvement of health literacy can help individuals to tackle the determinants of health better as it builds up the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand and use of information to promote and maintain good health [1]. Schools are essential in helping students to achieve health literacy [2]. The concept of the health promoting school (HPS) has been advocated as an effective approach to promote health in schools [3, 4]. It embodies a holistic, whole school approach in which a broad health education curriculum is supported by the environment and ethos of the school and shifts health into a more dynamic and political domain to address the determinants of heath [2, 5]. Healthy Schools Award schemes are very popularamong the European countries as structured frameworks acting as systems for monitoring and recognition of achievements [6]. Moon has shown positive award-related changes in terms of children's health behaviours, and that the awarded schools have more health promoting culture and organization [7].

The outbreak of Severe Acute Respiratory Syndrome (SARS) has highlighted the importance of maintaining a healthy and hygienic environment as one of the effective public health measures to combat infectious diseases, but the major challenge is that some of the most important public health measures are to be taken outside the health sector [8]. Schools have become an important setting to build up the skills and capacity for students, parents and the wider community to combat the challenges of outbreak of communicable diseases [9]. Rosen et al has demonstrated that a hygiene program can produce a sustained increase in hand washing rates among toilet-trained preschool children [10]. Hand washing has been shown to be an effective means to prevent spread of infection [11]. These findings illuminate the potential of schools as promising venues for promoting hygiene and health in prevention of infectious diseases.

The Centre for Health Education and Health Promotion, The Chinese University of Hong Kong (CHEP) launched the first territory-wide "Healthy Schools Award Scheme" (HSA) in 2001 [12]. It was modeled on the World Health Organization (WHO) Regional Office of the Western Pacific Health Promoting School (HPS) framework covering six key areas (health policy, physical and social environments, community relationships, personal health skills and health services) designed to assist schools in addressing particular health issues strategically [13‐16]. The scheme has developed a set of indicators and guidelines to meet the local needs. Each key area has a number of components with targets for the schools to achieve [13‐15]. The participating schools attended training programme on development planning at the start of the project helping them to appreciate the breadth of the scheme and consolidate their thoughts for appropriate action. The HSA project team met with the co-ordinating group of the school to identify and prioritize four to five areas of potential action. The project team visited the school at least once per term to offer advice and support and obtained detailed information on each of the activities for evaluation. The amount of support given varied from area to area according to the needs of the schools and the summary of health promoting activities have been described in the special issues [17‐19].

The process of selection of indicators for the scheme and also the accreditation process have incorporated advice and validation by a number of local and international experts in the field [15, 20]. A practical manual with detailed guidelines was developed for participating schools [13, 14]. "Personal health skills" is one key component, where basic knowledge and skills in hygienic measures and prevention of communicable diseases are incorporated in a variety of school activities like classroom teaching, interactive learning initiatives, community-wide health promoting campaigns, and teaching staffs are equipped with relevant training and resources [9, 13‐15, 20].

While process evaluations showed that health promoting activities had been successfully implemented in schools, the evaluation of the effectiveness of HPS reported a wide range of outcomes [21‐23]. This survey explores the differences in student perceptions, knowledge and health behaviours between schools that have adopted the HPS framework and those non-HPS. The Education Authority in Hong Kong recommended using the concept of HPS to improve school health and hygiene [24, 25] with the hypothesis that children in HPS schools more likely to perceive that their school is a healthier place. The result would have significant impact on the future planning, implementation and substantiation of HPS in different parts of the World as the problem of emerging infectious diseases becomes a global issue.

On the whole, students from the HSA group showed positive outcomes in most aspects of health and hygiene particularly the hygiene practice of students and actions taken by schools. It is not unexpected as HPS embodies a holistic, whole school approach to personal and community health promotion [27]. The Hong Kong Healthy Schools Award scheme builds on the concept of HPS which helps to create a supportive environment for healthy development in schools, home and the community [6]. Studies have shown that students from schools which had comprehensively embraced the HPS concept as indicated by attaining the 'Healthy School Award', were better, in terms of health and educational outcomes, than students from schools that did not reach the standard of the award [28, 29].

St Leger and Nutbeam [30] stated that HPS contributes to four school related outcomes. They are: (a) lifelong learning; (b) competencies and behaviors; (c) specific cognate knowledge and skills; and (d) self attributes. Therefore HSA schools would confer a great impact on school health and hygiene, in addition to students' health habits, as was demonstrated in the present study.

Positive changes were observed in certain aspects of school health and hygiene particularly in getting relevant health information from various reliable sources amongst secondary students in the HSA group. Previous studies have indicated the potential for a settings approach to school health, like the Hong Kong HSA scheme (HKHSA), to provide a promising strategic framework allowing health literacy outcome to be achieved [2, 31]. This group of schools also established actions to promote better health and hygiene as the schools participated in community cleaning activities and the parents also supported the schools in cleaning activities. This study reveals that these HSA schools have also organized more health promotion activities. This moves to a more collaborative community-based approach for students to learn, as opposed to a teacher-dominated school hierarchy [2], is one of the strategies to achieve critical health literacy [1].

School-based implementation of HPS was shown to be associated with significant greater levels of positive personal health habits. Although this study is cross-sectional and no cause and effect can be established, it would still highlight how HKHSA might exert its influence individually as well as the school level. Although some of the significant findings of this study is marginal, HPS has only been implemented over a short duration in Hong Kong. HPS programme has been shown to be effective if the intervention is intensive over a long duration [32]. Recent evidence suggests that the way the school is lead and managed, students' experiences in participating and taking responsibility for shaping policies, practices and procedures, teachers-students relationship and school engagement with its local community including parents actually builds many protective factors for health and minimises risk taking behaviour [32‐35]. Many of these gains have occurred without a specific health 'intervention'. It appears that a whole school approach to build and maintain a caring school social environment might be the most effective way in achieving good health outcomes.

However putting the HPS in practice takes considerable amount of time and efforts and effective implementation requires commitment and support of various schools' stakeholders. The success of HPS depends heavily on teachers' training like Health Education diploma programmes, which could introduce the concepts to the teachers so they can start making improvements on some fundamental areas of school health and hygiene [36, 37]. With time and more teachers being exposed to the concept, teachers would then gradually develop their schools to become HPS. The primary school students in HSA group have shown to have better knowledge scores. Although the difference in knowledge scores between two groups is not statistically significant in secondary schools, it is well known fact that there are other factors in adolescents leading to behaviour and practice change apart from knowledge and belief.

There are some limitations of this study. Schools with more health conscious students or their families might be more willing to adopt HPS. The study design might not be able to control for that history which would have some threat to internal validity. It is a cross sectional survey so it might not capture the longer-term impact of HPS on health behaviours of students due to the different components of HSA interventions. The differences observed might or might not be due to the effect of intervention and future longitudinal studies are needed to ascertain the causal effect fostered by HSA. Furthermore, some outcomes were reported by students only and may involve recall in the past few months, and the effect of multiple comparisons should be taken into account when interpreting statistical significance. In addition, we assumed that randomized sampling minimized the heterogeneity of different clusters and demographic characteristics among schools, which have not been controlled for. This study did not comprehensively assess all the outcomes of HPS as there are different types of outcomes which require different methods of data collection. [14] A descriptive design was adopted instead of randomised control study design because one cannot randomly select schools from all schools in Hong Kong as intervention group since schools need to comply with the standards of HPS to make it an effective programme.

The study has demonstrated that schools involved in HPS activities through the HSA scheme in Hong Kong had more favorable hygiene practice of students, school environment and atmosphere in health and hygienic practice. Although all schools in Hong Kong have health elements in the curriculum, the primary objective of HPS is to modify the behaviours of school students rather than information giving, so more positive changes are observed in those schools that participated and met the standards in the HSA scheme. These findings highlight the potential of HPS in equipping schools to handle public health crisis such as SARS [9]. Therefore it is highly recommended that schools would further enhance the practice of HPS to empower their students, staffs and parents to enhance preparedness of possible future epidemics of communicable diseases. [38].