Hawe dh vic november 2011 school hp (pp tminimizer)

Critically important whole school health promotion work has to be sustained: Shifting from program thinking to system thinking

Penny Hawe

Population Health Intervention Research Centre

University of Calgary , Canada

www.ucalgary.ca/PHIRC [email protected]

A CIHR Centre for Research Development in Population Health

http://www.ucalgary.ca/PHIRC

Take home message

Most effective HP programs seem to be those that harness dynamic properties of systems

We may be able to use these insights to design and sustain more effective interventions

Implications are wide ranging (but not too scary!)

Eras of health promotion

1990s

Testing phase

1970s and 80s

Sustainability phase

Systems phase

Early 2000s

Prevention Studies, Implementation Findings

Battish et al (1996) 33% of schools implemented the program properly

Rohrbach et al (1993) 79% teachers omitted program components

Taggart et al (1990) 45% teachers implement properly

Flannery et al(1993) 67% teachers miss key components

Dulak JA, J Prev & Intervention in the Community 1998;17:5-18

Evidence on what gets sustained

Proven effective

Consumer and practitioner involvement

$ or in-kind support from outset

Stable, mature host organisation

Compatible mission between host and program

Integrated, not run as separate unit

Financially viable

High level champion

Prevention Studies, Implementation Findings

Battish et al (1996) 33% of schools implemented the program properly

Rohrbach et al (1993) 79% teachers omitted program components

Taggart et al (1990) 45% teachers implement properly

Flannery et al(1993) 67% teachers miss key components

Dulak JA, J Prev & Intervention in the Community 1998;17:5-18

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Look inside the “black box” of the program to understand more about it and the change processes going on in and around it

Started to gain more appreciation of the schools, in built capacity of “the agents”,

8

A tale of two projects

Hutchinson Smoking Prevention Project (USA)

Gatehouse Project (Australia)

8

5

6

Gatehouse Project

26 Australian metro and rural high schools

A collaborative intervention to improve social environment at school

Randomised controlled trial

Centre for Adolescent Health , University of Melbourne

Gatehouse Project – Organisational Development over 2 years

EntrySurvey, interviewsFeedbackPriority settingActionsImplementationEvaluation

Action team (staff, students, parents)Part time facilitatorCurriculumProfessional development

Towards a more positive social environment(Patton G, Bond L, Butler S, Glover S)

Classroom Security• clear and agreed class rules• no put-downs• maintaining privacyCommunication • promoting listening to others• promote opportunities for one-

on-one interaction with teachers

• physical layout of classroom• small group workPositive regard through

participation• part of the group and have

something to contribute• promote acknowledgment of

others contribution and work

Whole school Security• implementation and monitoring of

victimisation prevention strategies

Communication• moving towards organisational

change• peer support program –

coordination and training• student-teacher engagement

outside of class eg mentoring

Promote participation• organisational change to allow

student representation• promotion of extra-curric. activities• create opportunities for feedback to

students (and teachers)

The Gatehouse Project: changes in health risk behaviour in year 8 students after 2 years

0

20

40

60

80

100

120

Smoking Regularsmoking

Bingedrinking

Cannabis WeeklyCannabis

% o

f gr

oup

Comparison schools

Intervention

All analyses adjusted for previous level of substance use in the school

Key milestones

2001 Whole school mental health promotion symposium, Calgary

2002 - 2004

CORE high school

pilot

Social network analysis is the study of social structure.

It maps relations among people (or organisations)

A person’s position in a structure determines the opportunities or constraints that the person will encounter

-information, - help -viewpoints -approval/disapproval - affirmation of worth

The basics

Nodes, actors

Ties - role based (eg brother of, boss of)

-cognitive, affective (eg., likes, knows)

- actions (eg., talks to, plays with)

Density and centrality

School Staff and Teacher Network Survey (complete network n=50)

Assessed - knowing by name- regular conversations- knowing more personally- advice seeking- socialising

Twice. At the start, and one year after the intervention.

Staff. Advice seeking a year ago

Staff. Advice seeking now

Density of relationships, before and after (%)

Before After

Knowing by name 66 95

Knowing more personally 29 39

Regular conversations 26 41

Seeking advice 15 21

Socialising with 6 8

Insight

Maybe this is the ‘real magic ‘ of the intervention

Maybe explains why it`s easy to do things in some places and harder in others

Led to workplace-focused school improvement work in CORE as essential first step

Plus now doing social network analysis routinely with the kids

Students. The talk-to-when-upset network at Time 1One elementary classroom

Students. The talk-to-when-upset network at Time 2,same class

Play at school together, grade 6, baseline assessment coded by typical peer rated behaviour

Key milestones in the transfer2001 Whole school mental health promotion

symposium, Calgary

2002 - 2004

CORE high school

pilot 2004-2008 4 elementary and

one junior high

2009/2010 CORE final pilot

(elementary)

Stronger teacher/workplace focus

Extended social network analysis into the students

Added a cortisol assessment

Launched an RCT in 2010/2011


Hutchinson Smoking Prevention Project (USA)

Gatehouse Project (Australia)

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Goliath versus David?

Individual versus system?

Controlled versus flexible?

Unlucky versus lucky?

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More about contextsÉ

School 1

School 2

School 3

School 4

Change in principal 1 0 6 1

Change in vice principal

vacant 2 2 1

Staff turnover 43% 35% 74% 59%

Student turnover 65% 41% 59% 27%

Contextual turbulence in a whole-school health promotion projectover four years

Omstead et al. Advances in School Mental Health Promotion 2009

Thinking of my teachers this term, I really like……..

All of them 14%

Most of them 42%

Half of them 16%

One or two 25%

None of them 3%

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Implications of moving from program thinking to system thinking

1. Can’t activate and draw on what each part has to give if a system not interconnected in first place – social health groundwork

2. Start where they are at (fix lights in the toilets)

3. Don’t just offer your favourite program – help sort, choose, add and take away

4. Recognise the function played by “useless” programs

DARE Drug Abuse Resistance Education

• 33 million children 1983-1997, no evidence of effectiveness

• Costly. Average of $217-$334 per child per year

• Renovated at cost of $13.7m, still not known if effective


5. Give more power to school to choose but regulate the quality of the HP offerings including those in non profit and voluntary sector


5. Give more power to school to choose but regulate the quality of the HP offerings including those in non profit and voluntary sector

6. Measure background contextual change

Incidental references to smoking in Calgary Herald and Edmonton Journal, over a 3 year period

0

10

20

30

40

50

60

incidental - as an entertainer/sports incidental - other than entertainment

May-01 Apr-02 Jan-03


5. Give more power to school to choose but regulate the quality of the HP offerings, including those in non profit and voluntary sector

6. Measure background contextual change

7. Increase feedback about performance

8. Reward evaluation regardless of results

9. Widen what is measured (including cost)


10.Sustain, invest, expand, mainstream

11. Prompt others to care – public demand and accountability as a new system driver for health promotion

....”My School”