Health Promotion International, 2017;32:218–230
doi: 10.1093/heapro/dau018
Advance Access Publication Date: 28 March 2014
Article
Implementation practices in school health
promotion: findings from an Austrian
multiple-case study
Michaela Adamowitsch*, Lisa Gugglberger and Wolfgang Dür
Ludwig Boltzmann Gesellschaft, Ludwig Boltzmann Institute Health Promotion Research, Untere
Donaustr. 47/B09, Vienna 1020, Austria
*Corresponding author. E-mail: michaela.adamowitsch@lbihpr.lbg.ac.at
Summary
Since the 1980s, schools have been recognized as an ideal setting to promote students’ and teachers’
health. Three decades after the development of the Health Promoting Schools (HPS) approach, however, there is still only limited knowledge about the implementation of health promotion (HP) activities
in this setting. Some studies indicate that schools change original concepts significantly when adapting them to local context in the course of implementation. In this paper, we pursue the question how
HP is practiced in schools that have agreed to implement HPS concepts from regional service providers (SPs), using data from a multiple-case study conducted in an Austrian province. Furthermore,
we explored the HP activities chosen for implementation and the decision-making leading to their implementation. We draw on 22 interviews with members of the school community and provincial HP
SPs, 9 group discussions, and 10 observations we have carried out within three schools between
November 2010 and January 2012, supplemented by a variety of documents. We have identified 40
different HP activities, of which most targeted students, while mostly focusing on physical activity
and/or psychosocial health. Planning, coordination and cooperation at the school level were minimal.
Decisions for or against activities were seldom taken together, but taken individually due to personal
knowledge, interests and experiences, perceived needs and problems, already existing activities and
external influences. The findings suggest that schools rather remain with a traditional topic-based approach instead of realizing an integrated whole-school approach and indicate a need for more support
especially during the early phases of implementation.
Key words: school health promotion; implementation; exploratory multiple-case study; decision-making
INTRODUCTION
Based on the principles of the Ottawa Charter (WHO,
1986) and recognizing the importance of supportive settings for health, the Health Promoting Schools (HPS)
concept was first introduced in the 1980s. After placing
the initial emphasis on programs targeting specific health
aspects, a shift of focus set in towards HPS programs and
frameworks that follow a holistic approach and aim at
creating health-promoting environments (Inchley et al.,
2000; M~
ukoma and Flisher, 2004). The aim of this approach is to achieve whole of school implementation,
thereby addressing all stakeholders and realizing health
promotion (HP) as a coordinated school-wide activity
(WHO, 1996). Areas of intervention as suggested by St
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V
Implementation practices in school health promotion
Leger et al. are school policies, the physical and social environment, the formal and informal curriculum (individual health skills, action competencies), community links
and health services (St Leger et al., 2010).
Evidence from evaluation studies supports this
whole-school approach, assigning it a greater effect on
health and educational outcomes than solely classroombased topic approaches (Stewart-Brown, 2006; St Leger
and Young, 2009). Nevertheless, the latter still prevails
among schools while the HPS approach is rarely effectively translated into practice (Deschesnes et al., 2003;
St Leger and Young, 2009). While factors such as ‘an extended timeframe for effective change’, ‘political and financial support’ and ‘the involvement of critical
partners’ are yet known to decide about implementation
success of the HPS approach, there appears to be a
dearth of detailed information on local implementation
design and practice [(Gleddie, 2012), p. 83].
Consequently, the literature points to the need for more
research on the implementation of school HP programs
under real-life conditions and on key barriers and facilitators to high-quality implementation (Deschesnes et al.,
2003; Barry et al., 2005; Samdal and Rowling, 2011;
Gleddie, 2012; Dür, 2013).
Austrian schools can seek assistance from different
HP service providers (SPs), commonly working at regional/provincial level, such as statutory health insurance providers and health agencies (Gugglberger, 2011).
The Austrian situation is a similar one as described
above: insights into what is going on during HP implementation processes within schools are scarce and there
is only limited (scientific) knowledge about how HPS
concepts from SPs are finally realized. As schools seem
to significantly change original HPS concepts (Kremser,
2011), it can be assumed that a great variety of HPS
approaches exists in practice.
Theoretical underpinnings
We developed a preliminary understanding of how the
phases of implementation may be conceptualized, building on the stages of implementation as described by
Fixsen et al. (Fixsen et al., 2005), findings of a case study
in an Austrian school (Kremser, 2011) and insights from
systems and complexity theory (Keshavarz et al., 2010;
Dür, 2013). For the purpose of this study, we roughly
differentiated four overlapping phases of implementation that guided our research:
i. Adoption: the school makes the strategic decision to
start with HP
ii. Program installation: resulting in a (more or less)
specific plan on HP topics, the school wants to work
219
on, persons that will be involved and eventually first
ideas on possible HP activities
iii. Planning measures: plans for HP activities to realize
the HP program are developed
iv. Intervention: plans of HP activities are put into
practice, leading to HP outcomes
It is assumed that during each of these stages a characteristic mix of internal and external factors plays an important role in determining its result. Schools,
understanding them as social complex adaptive systems,
are strongly interrelated with their environments and
constantly respond to new information and requirements (Keshavarz et al., 2010). What schools do, however, and how they react to external influences rather
depends on (internal structures of) the system itself than
on expectations of the outside world (Luhmann, 1995).
Further phases of implementation could have been defined but were not relevant for this study. Fixsen et al.
(Fixsen et al., 2005), for example, also conceptualized
the stages ‘innovation’ and ‘sustainability’.
This paper is one of the first attempts to shed light
upon the implementation of school HP in Austria, by illuminating the question of how HP is practized in schools
that have agreed to implement an HPS concept by joining
a regional SP. We further pursue the questions which HP
activities can be observed and how and by whom the decision to implement a specific activity is taken.
METHODS
Study design
We chose an exploratory multiple-case study design to
examine schools that cooperate with SPs of school HP in
an Austrian province. A case study approach is a highly
flexible approach that allows investigating contemporary events (such as HPS programs and their implementation process) within real-life social settings (such as
schools), which can hardly be controlled by researchers
(Inchley et al., 2000; Yin, 2009).
Choice of schools was based on purposeful sampling
(Coyne, 1997): based on three expert interviews and
consultations with responsible representatives from the
provincial school board and the two provincial SPs, we
included three schools (cases). Our intention was to recruit schools that differ in regard to type of school (primary, academic secondary and general secondary), the
SP they are cooperating with, and implementation status
of the HPS concept [initial vs. full implementation, cp.
(Fixsen et al., 2005)]. The aim was to achieve maximal
variance regarding these characteristics due to the
study’s explorative approach.
220
Case A is a primary school (grades 1–4) that employed 12 female class teachers—each one assigned to
one class—at the time of data collection. The school, situated in a wealthy village, had a total of 267 students
aged 6–10 years. Case B is an academic secondary
school (grades 5–12) comprising 37 classes, located in
the second-biggest town of the province and attended by
926 students (aged 10–18), who were taught by a total
of 82 subject teachers (23 male, 59 female). Case C, a
general academic school (grades 5–8) with 11 classes,
situated in a small rural town, had 251 students from 10
to 14 years and 26 subject teachers (5 male, 21 female).
Following a shared agreement, one SP (a health insurance provider) supports predominantly primary
schools in becoming ‘healthy primary schools’, like Case
A, while the second provider (a provincial health
agency) assists only secondary schools (schools B and C)
in realizing an HPS concept. Both SPs declare to base
their HPS concept on common principles of the HPS approach [e.g. empowerment and participation, democracy, collaboration, sustainability (WHO, 1997)] and
concentrate on the areas physical activity, nutrition, psychosocial health, disease prevention, ecology and the
school environment. They offer guidance, financial support for HP activities/projects, brochures and supporting
material and organize exchange among schools within
their respective HPS network.
By joining an SP, the three schools formally committed to become a ‘healthy (primary) school’, meaning
that they implement a whole-school approach to HP as
promoted by SPs’ HPS concepts. Referring to terms
from Fixsen et al. (Fixsen et al., 2005), schools introduced to us as ‘initial implementation schools’ (schools
A and C) were supposed to be at the beginning of implementing the HPS program they developed according to
local requirements. To meet SPs’ requirements, they
should have nominated one of the teachers as health coordinator (coordinating local HP implementation) and
installed a supporting HP team. Such a team should at
least consist of the headteacher, further teachers and a
so-called moderator, who, as a representative from SPs,
advises schools and gives some on-site support. The ‘full
implementation school’ (school B) was considered a
‘flagship school’ that already cooperated with the SP
since the pilot phase. Having achieved ‘full-operation’
status would mean that their HPS program was fully implemented and institutionalized (Fixsen et al., 2005).
Data generation
Between November 2010 and January 2012 a team of
researchers applied a mix of mostly qualitative but also
M. Adamowitsch et al.
quantitative methods: a baseline survey of students,
teachers and headteachers was conducted at the beginning of the school year 2010 11 to obtain, for example,
demographic and health data; qualitative data generation occurred in a continuous process spanning over the
entire period of investigation and focused on ongoing
activities and processes. This article will focus on findings from 22 qualitative in-depth interviews with headteachers, health coordinators, providers of single HP
activities (teachers as well as external HP practitioners),
municipality representatives and SP moderators. Further
sources of data this article will draw upon are nine homogenous group discussions with teachers, students and
parents, as well as mixed group discussions that included headteachers. These sources are supplemented by
findings from 10 overt participant observations and a
great variety of documents, for example schools’ annual
reports, websites containing information on their HP activities and documents written for SPs. Table 1 gives an
overview of the data.
Interviews as well as group discussions followed a
semi-structured topic guide; most took place in the respective schools. Interviews lasted between 15 and 70
min, group discussions between 27 and 65 min.
Duration of interviews/discussions depended on the
number of participants, their available time and lengths
of topic guides. All of them were recorded after obtaining interviewees’ written informed consent and transcribed. Field notes were taken during observations and
re-written in greater detail shortly afterwards. Prior to
Table 1: Overview of data
Interviews
Headteacher
Health coordinator
HP activity provider
HP service provider no. 1
Moderators from service
provider no. 2
HP service provider no. 2
Municipality
Group discussions
Teachers
Pupils
Parents
Mixed
Participant observations
Persons involved in
HP activities
School A
School B
School C
1
5
1
–
1
1
5
–
1
1
1
–
–
1
–
2
–
1
1
–
1
1
1
1
1
1
1
1
–
–
5
5
–
1
Implementation practices in school health promotion
conducting the study, ethics approval was obtained
from the provincial school board.
Data analysis
For the purpose of this article, thematic analysis following Froschauer and Lueger (Froschauer and Lueger,
2003) was undertaken with the assistance of ATLAS.ti
software. Five stages of analysis were conducted in an iterative manner: (i) Development of thematic categories:
identification of themes in the data by repeatedly reading the material and coding text extracts according to
the central statements; coding was guided by research
questions (deductive) as well as data-driven (inductive).
(ii) Development of sub-categories within thematic categories through the identification of important characteristics of themes. (iii) Structuring of thematic categories
and sub-categories by comparing and linking them in regard to the research questions. (iv) Collection of the relevant coded extracts within the relevant thematic
categories and sub-categories and (v) summarizing, interpreting and describing them.
Thematic coding was first applied to interviews with
headteachers and health coordinators, focusing on the
history of the decision to adopt HP, their respective HP
program (activities and structures, decision-making, assignment of responsibilities, etc.), and its relation to
other school routines. These interviews informed further
interviews with providers of HP activities centering on
issues of planning, implementation and intended aims.
Those were added to the analysis as a second dataset, together with protocols of observations. Finally, group
discussions—focusing on general topics of school life
and perceptions of school HP—and documents complemented the analysis. The categories were created and organized by the main author of this paper and discussed
with other members of the research team: schools’ HP
practices were arranged and will be presented according
to the four phases of implementation (overall-themes)
we outlined in the Introduction section. The phases
‘planning measures’ and ‘intervention’ will be further
elaborated by describing the sub-themes ‘HP activities
chosen for implementation’ and ‘decision-making processes in regard to HP activities’.
RESULTS
Adoption
At the time of data collection, it was the 4th year of cooperation between the academic secondary school (Case
B) and their SP and the 3rd year for the general secondary school (Case C). In the former, the headteacher was
221
the initiator of school HP who had suggested its adoption in a staff conference shortly before starting the cooperation. In the latter, the ‘driving force’ was a new
teacher (the prospective health coordinator), who had
been referred to the SP by the headteacher when showing an interest in school HP. The primary school (Case
A) cooperated with its SP for the second year, according
to SP documents adopting a physical activity focus. The
reason for approaching an SP was that they needed
funding to continue an already existing HP activity.
Schools A and B had both started implementing HP activities prior to joining the SPs’ regional HPS networks,
with the former drawing on >10 years of experience
from diverse HP projects.
Program installation
For the period investigated, we could not identify any
HP teams as suggested by SPs. Hence, we had to rely on
interviews with headteachers, coordinators and implementers of single HP activities to learn about HP implementation practices. School A’s coordinator did not see
herself as such—she had only been appointed pro forma
by the headteacher in order to fulfil formal requirements
from SPs. The coordinator from school B fulfilled the
role of an assistant supporting the headteacher in the
management of organizational HPS tasks, but did not
coordinate HP activities, either. In regard to program
planning, we found that there was only minimal planning, coordination and cooperation at the school level.
Interview data revealed that the persons delivering HP
activities could only give information about their own
projects, and neither headteachers nor coordinators
were able to give a complete overview of the HP activities we could identify at their schools (see Table 2). The
documents we analyzed were not in full conformity with
our findings, either—not even annual reports schools
had to write for SPs. These reports were almost the only
form of project management we could observe.
Planning measures and intervention phase
Health coordinators from schools A and C played a vital
role as providers of HP activities. The latter initiated
and implemented almost all of the measures at her
school, as neither she nor the headteacher succeeded in
motivating other teachers to participate in school HP.
The coordinator from school B delivered no measure at
all. Independent from type of school, the great majority
of measures had been planned and delivered by teachers,
often single-handedly. The headteacher from school B
was the only who also actively acted as an implementer.
At school A, parents were implementers, too, and
Weekly dancing class with performances from time to time (optional
subjecta, initiated 10 years ago by HC)
Buddy program with kindergarten (get together with physical activity
in the park between preschoolers and grade 3 students; 1 day event
implemented for the first time)
Weekly choral singing class incorporating breathing exercises and
some physical activity, with performances from time to time
(optional subject,a initiated 10 years ago)
A
Physical activity &
social
commitment
Physical activity &
psychosocial
health
A
C
B
Supporting trainer for PE lessons, also as further training of teachers (1
PE lesson per week for every class, 1 semester per year, initiated 10
years ago)
Option to choose a class with a PE focus (having one additional PE lesson per week, initiated 10 years ago by HT)
Annual swimming contest (grades 3 and 4, 1 day, initiated ‘many
years’ ago by HC)
Weekly posture and back exercises (optional subject,a initiated 14
years ago)
Bag containing small sports and play equipment for free usage during
breaks (1 for every class)
‘Vitality course’ consisting of sports and playing equipment in the
schoolyard, e.g. seesaws, balance whirligig (installed on selected
days, developed 3 years ago, permanent installation intended)
Weekly teachers’ sports group led by PE teachers receiving remuneration through school funding (newly implemented)
Occasional 1 day events promoting physical-activity trends (e.g. external trend-sport day; jongleur at school)
Advanced winter-sports week (extended program compared with traditional winter-sports week at grade 6 and 7)
Training for the Austrian women’s run (Saturday morning) and
participation
Weekly athletic sports group (optional subjecta with occasional participations in track meetings)
Annual school-wide charity run (with the buddy program being continued, see further down; initiated around 3 years ago)
A
Physical activity
Health promotion activities
School
Areas of
intervention
Table 2: Implemented health promotion activities identified for the period of investigation
HT
HT, HC, teachers
Physiotherapist, HT,
municipality
–
Students
Students
Students
HC, HT, local school
authority
Head of kindergarten,
sport scientist, HT
HT, choirmaster
Students,
preschoolers
Students
Students
HT, teachers, local
sport scientist
HC
HC, HT
Wider school
community
HC
HC, (HT)
Students,
mothers
Students
(continued)
Choirmaster (a
teacher)
Local sport scientist,
kindergarten
HC
Local sport scientist,
teachers
HC
HC, (HT)
Students
External providers
HT, PE teachers
HT
PE teacher, HT
Teachers
HT, sponsors
HC
Physiotherapist
Teachers
Class teachers
Trainer from local
sports organization
Primary implementers
Students
HT
Students
Students
HT, HC, trainer,
municipality
Persons involved in
decision-making
Students
Target groups
222
M. Adamowitsch et al.
Nutrition
Psychosocial health
Areas of
intervention
Table 2: (Continued)
C
B
A
C
B
A
B
School
‘Healthy breakfast/healthy snacks’, learning stations developed and
guided by grade 12 students for grade 5 students (once or twice a
year as part of ‘household economics’ class; initiated 2 years ago)
‘Healthy snacks’, grade 5 students prepare and sell healthy snacks in
the main break from time to time (initiated 2 years ago)
Compulsory lectures and optional workshops promoting teachers’
health (burn-out prevention, fitness, back health; newly
implemented)
Prevention of violence by the medium of theatre (class-wise), including
information for teachers and a parents’ evening (implemented for
the first year)
Addiction prevention comprising a 3-day program at grade 7 (interactive theatre; learning stations; visiting a climbing crag; initiated 4
years ago with assistance of the regional department for drug prevention)
‘Mediation and social learning’, an optional subjecta offered at grades
9 11, including 3 days with an outdoor education specialist; this
course enables students to serve as peer-mediators at school (initiated 4 years ago)
‘Student parliament’ to give students a say regarding, e.g. the installation of a school buffet (occasional meetings of elected student representatives and interested students; initiated 1 year ago)
‘Healthy snacks’ provided once a week by parents in their child’s class
Policy banning sugary drinks and promoting water as part of the house
rules; students are allowed to drink water anytime during lessons;
healthy drinking habits are occasionally addressed in class
‘Apple day’, apples are delivered by the school’s parents’ association to
each classroom once a week (newly implemented)
Occasional guided tours offered by the local heathlands association
and park maintenance activities (class-wise)
Health promotion activities
School
community
Students
Students
HC, (HT)
Parents’ association,
school community
HT, school’s
nutritionists
HC
(continued)
Nutritionist (a
teacher)
Parents’ association
Class teachers
Parents, class teachers
Class teachers,
parents, (HT)
–
Students
School
community
HC, SP moderator
Teacher, students,
outdoor expert
Teachers (2), external
providers
HC, SP moderator,
HT
Teacher, HT
Biology teachers,
(HT)
External provider
Teachers, local
association
HT, HC, external
experts
Primary implementers
Students
Students
Students
Sponsors, HT,
teachers
HT, HC, teacher
representation
Teachers
Students
–
Persons involved in
decision-making
Students
Target groups
Implementation practices in school health promotion
223
Safety & physical
activity
School’s physical
environment &
ecology
Health-promoting
teaching and
learning
A
Schools’ physical
environment
A
B
A
A
C
B
School
Areas of
intervention
Table 2: (Continued)
Using a playground in the park opposite the school as schoolyard (created 4 years ago by a so-called playground office with participation
of students and parents)
Planning of a new school annex comprising a bigger teachers’ room,
new classrooms with ergonomic furniture and ergometers, drinking
fountains, a fitness room and gym (participation of teachers, students and parents in the planning stage; start of construction
planned for the following school year)
Painting school’s walls with new colors (assistance of a local painter;
realized after joining the SP)
Establishment of a recreation room for students (as a result of the
‘Student parliament’)
Ongoing recycling, waist avoidance, clean-ups of public green space
(e.g. municipality representatives visit school from time to time to
talk with students about these topics)
Lessons combining (social) learning and physical activity, also as further training of teachers (delivered in two classes by an external
expert/parent five times per year, the second year in a row)
Relaxation and kinesthetic exercises and physical-activity breaks during lessons instructed by teachers
‘Bat night walk’, walking tour at night for grades 3 and 4 students and
their parents to promote children’s interest in life science (implemented for the first year)
‘Brain-Gym’, short physical activity breaks conducted by teachers in
class to enhance students’ concentration (delivered in two classes,
three times per week; with two control groups and scientific evaluation; newly implemented)
‘Safe ways to school’, annual road safety education (1 day at the beginning of each school year)
Mobility education comprising a 1-day event as part of the European
mobility week (organization of a walking school bus, workshop for
parents) and participation in a community initiative promoting
walking
Health promotion activities
HT, teachers, local
school authority
Students, (HT)
School
community
Class teachers
Class teachers
Local police
Community, teachers
–
Municipality, HT
(teachers)
Students
Students,
(parents)
(continued)
HT, teachers
Students
Students
Woods association
Expert working for an
SP
Expert, HT, teachers,
SP
Municipality,
teachers
–
HT, HC
HT, respective
teachers
—
Students
Students
HT, municipality,
teachers
HT, state real-estate
company, school
authority
School
community
Students
(School)
community
‘Playground office’,
class teachers
–
Students,
community
HT, state real-estate
company, school
authority
Primary implementers
Persons involved in
decision-making
Target groups
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M. Adamowitsch et al.
Expert working for an
SP
Paramedic (a teacher)
–
Teacher (background
as paramedic), HT
–
Students
School
community
School
community
, no available data.
Free after-school course, usually once a week; HT, headteacher; HC, health coordinator; SP, service provider;
B
Health in general
HP activities chosen for implementation
a
B
Physical health,
safety & social
commitment
Annual dental hygiene education delivered by an expert working for
an SP (twice a year, in every class)
School medical service, a first aid course offered as optional subjecta at
grades 9 12; students can serve as paramedics at school according
to daily service schedules; first aid courses are also offered to teachers (initiated 3 years ago)
School’s annual health day, a 1-day event with lectures, workshops
and healthy food for students, teachers and parents to promote
healthy lifestyles
A
Physical health
225
external HP practitioners played a greater role than in
the other schools.
SPs/moderators visited schools A and B only one or
two times a year and described them as being very independent. In schools B and C, moderators usually met
with headteachers and coordinators; in school A, SPs
only met with the headteacher. After having approved
schools’ project plans at the beginning of a school year,
SPs seemed to rely on the rather vague annual reports to
monitor implementation outcomes. Although great
changes of original HPS concepts were observed (no HP
teams, no coordinators, no school-wide, overarching HP
program/strategy that would unite single HP activities,
etc.), schools were still able to realize a multitude of HP
activities, as described in the following section.
–
Primary implementers
Persons involved in
decision-making
Target groups
Health promotion activities
School
Areas of
intervention
Table 2: (Continued)
Implementation practices in school health promotion
As our intention was to learn about the current understanding of school HP within schools, we only treated
measures as ‘HP activities’ when they were clearly related to school HP by members of the school community
or within documents. This resulted in the identification
of 40 different HP activities that were effectively implemented between November 2010 and January 2012
(Table 2). We would have identified a further 13 (potential) HP activities, but as they were not documented or
mentioned to us as such, they will not be considered in
this article. It turned out that school A implemented by
far the most HP measures, while at the same time being
the smallest school with respect to the number of students and staff members. This was due to the fact that
almost all of the activities had been initiated long before
seeking the SP’s support 1 year ago and to the great
number of internal and external implementers. In comparison, school C implemented the least measures, employing more than twice as many teachers. It needs to be
considered that in this school only the headteacher and
the coordinator were actively engaged in HP, initiating
first HP activities at the time of joining the SP.
Areas of intervention
Based on interviewees’ descriptions of HP activities, we
assigned them to different subject areas (see Table 2).
Most measures could be allocated to more than one
area. Measures promoting physical activity clearly prevailed, followed by the promotion of psychosocial
health; these two areas also often went along. Each
school implemented some activities to promote the consumption of wholesome food and snacks and to improve
the physical environment. Measures promoting health
via the areas physical health, safety, social commitment
226
and health-promoting teaching and learning were mentioned in Cases A and B. The sole health-promoting activity that united the entire school community as well as
different health topics was a school-wide, annual health
day in the so-called full implementation school (Case B).
Although many of the identified HP activities appeared to be isolated stand-alone measures, usually delivered only by one, sometimes by two persons, all of the
schools managed to realize not only behavioral interventions but at least as many that combined behavioral
approaches with sustainable changes of schools’ physical
environment or the curriculum (e.g. installing optional
health-promoting after-school subjects or an additional
trainer for PE lessons). Healthy policies seemed to play a
minor or no part at all: only one teacher mentioned a
house rule that banned sugary drinks (Case A).
Document analysis revealed the existence of further
health-promoting house rules in secondary schools (e.g.
bans on smoking/drug use and codes on behavior), but
they were not mentioned in the context of HP. Out of all
HP activities, we identified only one measure that was
(externally) evaluated (‘Brain-Gym’, Case B). Many of
the implementers stated that they relied on informal
feedback to assess the effects of HP.
Well, you cannot try out to see what they [the children]
would be like if there would be nothing happening, but
sometimes I really have children where I am surprised,
they attend [the back exercise class] from [grades] one to
four, where I finally think, yes, that’s looking good. Not
everyone, but many are simply doing better then.
(Interview, HP activity provider, school A)
A great deal of the HP activities was implemented over a
short period of time (often only 1 or 2 days a year), but
repeated annually. There were also many occurring once
a week, such as healthy snack initiatives or optional
after-school subjects, also being implemented every
year. Most of the measures targeting students were implemented on a classroom level, several on a grade level,
but each school also had many activities, especially
after-school subjects, where students from several grades
came together. At school B, the headteacher favored
peer activities.
Target groups
At each school, the great majority of activities aimed at
promoting students’ health and well-being: 26 out of the
40 activities displayed in Table 2 exclusively addressed
students. Some measures targeted the school community
as a whole, particularly improvements of the physical
environment. Parents were occasionally involved in HP
activities, especially at primary-school level, however,
M. Adamowitsch et al.
were never explicitly named as a target group, although
a weekly running training (Case C) and the already mentioned health day (Case B) clearly targeted parents’
health, too.
The only school that had recognized teachers as a
target population was school B. The coordinator from
school C would have wanted to implement measures to
enhance teachers’ well-being, too, but the headteacher
had doubts in regard to feasibility. For Case A, no intentions to promote teachers’ health were observed at all.
Decision-making processes in regard to HP
activities
Analysis showed that the decision for or against implementation of a health-promoting activity was seldom
taken together, in, e.g. a democratic process. Instead,
implementation of HP activities usually resulted from
decisions made by the later implementers (the respective
teachers and experts from outside the school) and the
headteachers. Reasons for not realizing or continuing an
HP activity were the lack of time (Cases A and B) and/or
support (Cases A and C), either on part of the headteachers or teaching staff. Elected panels of teachers,
parents and—in the case of secondary schools—students
decided upon several school issues, but HP was no matter of their concern.
The headteacher from school B used to base some
general decisions (e.g. class times) on surveys among
school-community members, but pointed out that teachers lacked time and remuneration to participate more in
decision-making processes. The headteacher from school
A explained that while they sometimes decided democratically in staff conferences, she—as the executive—
would decide alone if they could not reach an agreement. She described herself as a switch point, where a
multitude of offers and ideas converged, and pushed the
implementation of external projects that caused no costs
and little effort. In case C, school HP was exclusively an
endeavor by the coordinator and the headteacher supporting her:
The teaching body is very, very hard to motivate and the
decision is only taken insofar, that I say, OK, I do it, and
go ahead with it then. (Interview, coordinator, school C)
Individuals with a certain interest commonly approached headteachers with an idea, which was generally embraced and often actively supported.
Headteachers from schools A and B, both very energetic
and dedicated in regard to school HP, also approached
(selected) teachers with an idea to implement a specific
HP activity if they heard about something interesting.
Implementation practices in school health promotion
Students in school B sometimes participated in the planning of HP measures, but we found no indication that
students had a say in regard to choice of HP activities in
any of the schools:
But, basically, saying that, yes, one can take an active
part and promote the health of students with the own
opinion, that, we don’t have. (Group discussion, student, school B)
We identified several factors influencing the decisionmaking in regard to HP activities:
Personal knowledge, interests and experiences
So, every school [in the ‘Healthy School’ network] orientates itself within the bounds of its possibilities, given
factors and, of course, according to the minds that it
has, according to their ideas. (Interview, coordinator,
school B)
One of the most prominent themes in the analysis of
decision-making processes was the influence of
individual-related factors such as professional education, out-of-school training/work experience, and personal interests. We found that many of the main players
in regard to school HP had a background in a healthrelated field. The headteacher of school B, the health coordinator from school C and a local provider of several
HP activities at school A were sport scientists, driving
especially the implementation of physical-activity-based
measures. Nutritionists, biology teachers and psychology teachers also played a decisive role regarding choice
of measures at school B. Non-academic education of
teachers and their out-of-school activities—as paramedic
or sports instructor (Case B), choirmaster or dance instructor (Case A)—were also influential, as were further
trainings of teachers, e.g. in the fields of addiction prevention or school mediation. Several teachers said that
they implemented a measure as a direct consequence of
a training/education, wanting to apply the newly gained
knowledge and skills.
Needs and problems leading to decisions for HP
Another important theme emerging in every school was
the identification of a need, a problem, or deficit, which
led to the decision to implement a certain HP activity.
Knowledge and experience, which resulted from the
individual-related factors described before, were very often interrelated with perceptions of needs (e.g. to deal
with topics such as violence, addiction or teachers’
health) and problems. Deficits or problems mentioned
by interviewees concerned, for example, school buildings, school yards, lack of adequate food supply, quality
227
of PE lessons or students’ eating and physical-activity
behavior.
Building on the existing
Schools A and B implemented HP activities that already
existed prior to committing to implement an HPS concept. In relation to decision-making processes, interviewees explained that some of them had originated
from earlier interventions, such as a past national pilot
project or individual class activities. In school A, the initiation of a series of activities dated back 10 years or
more, such as classes with an integrated focus on physical activity, and it seemed common for new teachers to
take over existing measures:
This [physical activity] focus goes way back. You come
and you take it over. You also agree upon it with parents, who are very glad and honour these school foci,
and then you live it. (Interview, class teacher, school A)
External influences and factors
A further theme schools shared was the dependence on
decisions by school authorities, as they needed to seek
their approval and financial support for certain measures: the Ministry of Education and the provincial education authority had to be convinced of the necessity to
build a school annex (Case B); painting the school’s
walls needed agreement and funding from local school
authorities (case C); and school A stressed its dependence on funds from local school authorities to continue
free subjects and the additional PE trainer:
[The headteacher] needs to apply for these free subjects
to the local school inspector and that is a big problem,
because every year, we have to go begging, more or less,
so that they are being continued. Because it is a question
of cost, free subjects have been cancelled successively.
Everything that is additional is simply being cancelled.
(Interview, coordinator, school A)
Interviewees reported that headteachers needed a lot of
commitment to get their demands accepted. In several
cases, obtaining funding from sponsors or SPs finally decided upon implementation of HP activities. SPs and
moderators seemed not to influence decision-making
processes in the ‘very independent’ schools A and B.
This was different in school B, where the coordinator
greatly relied on the moderator’s support:
Thank god, there was our advisor, who sorted a bit the
energies or the ideas and simply said, better to do less,
but to do it in a consequent way. (Interview, coordinator, school C)
228
A phenomenon only observed in the primary school
(Case A) was the strong influence of the municipality,
parents and other connections or interpersonal relations
on the offering and sometimes continuation of HP activities. While the school profited a lot from this, community relations also implicated obligations.
DISCUSSION
The present multiple-case study provides in-depth information on three Austrian schools (primary, academic
secondary and general secondary) that, at slightly different points in time, had sought support from provincial
SPs of school HP, thereby formally committing to implement an HPS concept. This article laid the focus on
schools’ local HP implementation practices, including
the specific HP activities chosen for implementation and
the decision-making leading to them. We could identify
processes for each of the different phases of implementation (adoption, program installation, planning measures,
intervention), thereby realizing that implementation occurred in an even lesser structured and planned way
than we anticipated.
In accordance with a review by M~
ukoma and Flisher
(M~
ukoma and Flisher, 2004), this study showed that the
investigated schools—independent from HPS implementation status as assessed by SPs—managed to implement
a surprizing multitude of HP activities from a wide
range of health topics, delivered predominantly by
teachers. This was especially true for the two schools
that had already started HP implementation prior to
joining an SP. Most of the implementers turned out to
possess expert knowledge in the respective area of intervention and the involvement of additional experts from
outside the school appeared to be very common as well.
From the wide variety of health topics addressed by the
three schools, it can be concluded that there exists a
broad understanding of health, but there was no mention of the importance to implement different strategies
at different levels. Health-promoting policies and institutional anchoring that should form part of the HPS approach [cp. (Rowling and Samdal, 2011) ] were, for
example, neglected, leaving potential reinforcing effects
unexploited.
Decisions to implement an HP activity were largely
based on the knowledge, personal interests, experiences
and concerns of committed individuals, showing the importance of teacher education and training, whereas
transparent decision-making processes and shared visions for becoming a health-promoting school lacked.
Similar observations were made in a previous case study
conducted during the first year of HPS implementation
M. Adamowitsch et al.
in a primary school located in another Austrian province: activities were planned according to teachers’ HP
knowledge, subjective perceptions regarding problems
in the class/school and intended HP aims (Kremser,
2011).
None of the three schools we investigated implemented organizational changes according to the conditions set by SPs: no coordinating HP teams were in
place, and none of the persons nominated as health coordinators really coordinated local implementation efforts, due to varying reasons (nominated only pro
forma; serving as headteachers’ assistant instead; lack of
supporting colleagues). According to the literature, it
would require negotiated and systematic planning, leadership and management to successfully realize a comprehensive approach to school HP (Deschesnes et al., 2003;
St Leger and Young, 2009; Samdal and Rowling, 2011).
The three schools, however, rather remained with a traditional topic-based approach, where everyone works
separately on different subject areas (St Leger and
Young, 2009) instead of implementing an integrated
whole-school approach where ‘selected activities in the
school environment come together to form an integrated
whole’ [(Deschesnes et al., 2003), p. 388]. Kremser
(Kremser, 2011), too, observed that the headteacher and
teaching staff—based on a joint decision—scaled down
the original HPS concept to mostly isolated classroombased projects; coordinated school-wide activities were
perceived as too labor intensive.
This scaling down of the HPS approach might be due
to the fact that teachers would have been required to
work together to a greater extent when implementing an
HP program than they are used to—Jourdan et al.
(Jourdan et al., 2011) state that higher degrees of collaboration can present a great challenge. Findings of an
Austrian study investigating schools that participated in
an HP pilot training course also indicate that collaboration is essential for implementation success of the HPS
concept (Flaschberger et al., 2012). We observed very
low levels of collaboration and coordination and agree
with Kremser (Kremser, 2011) that teachers can be described as ‘autonomous professionals’ (Hargreaves,
2000). Their focus appears to primarily be on the classroom level, whereas identification with extra-curricular
activities on the school level seems to be limited. The circumstance that headteachers have very limited opportunities to compensate teachers for their engagement in
extra-curricular (HP) activities might even reinforce this.
There is, for example, no way of officially assigning
working time to HP. Consequently, a multitude of observations were made in this study for the implementation phases where collaboration can be omitted (i.e.
Implementation practices in school health promotion
‘planning measures’ and ‘intervention’), whereas observations for the phases that would need to occur on the
school level and require staff to work collectively together (i.e. ‘adoption’ and ‘program installation’) were
limited.
It seems that SPs, although trying to lead schools towards a more structured and systemic approach, still
need to bring to mind the different possible areas and
levels of intervention for school HP, e.g. policies and institutional anchoring. The same holds true for the principles of the HPS approach, such as democracy and
participation. Training of collaboration skills should
furthermore be promoted as an important prerequisite
to successful HPS implementation. This study points to
the need for more support especially during the early
phases of implementation. This time should not only be
used to provide more information on the HPS approach
but to also establish real commitment and understanding among headteachers and teaching staff. For example
by outlining the benefits of implementing a more systemic and coordinated approach to HP versus an enormous number of isolated activities and its possible
contributions to schools’ core business of teaching and
learning.
Limitations and implications for further research
In matters of sampling, it may be regarded as a weakness
that we did not succeed in including a school that adhered to all of the requirements of HPS concepts, ergo
achieving full implementation status, since we made the
decision to rely on SPs’ selection of schools. Their particular choice of schools might be testament to either a
lack of insight into schools, a different understanding of
implementation stages (i.e. what constitutes full implementation) or merely to the non-existence of schools
that implement an HPS concept to its full extent.
Another limitation is that our findings are based on only
three schools. As the three cases differ in many aspects
comparability may be limited. The fact, however, that
all three schools, although being very different, made
similar changes in terms of narrowing original HPS concepts makes a strong case that Austrian schools are generally facing troubles with the implementation. In the
future, more research in a greater number of schools will
be required to test the hypotheses developed in the
course of this multiple-case study and to further investigate implementation under real-life conditions.
Furthermore, it has to be mentioned that this paper can
make no claims to completeness regarding the identified
HP activities. We did not include HP actions that were
not mentioned as such in the data. The HP activities we
229
described represent the understanding of HP that existed
within schools at the time of data collection.
CONCLUSION
Currently, (in Austria) health promotion does not officially belong to schools’ core business, which is teaching
and learning, as there is no political remit.
Consequently, school HP always rests with individuals,
whose commitment to a certain health topic is so vigorous that they are willing to invest the time and effort
these additional tasks require. Moreover, teachers often
do not regard it as part of their profession to coordinate
and organize while structures within schools do not necessarily fit a coordinated approach to school HP, and
the incentives and resources from the political level are
not sufficient.
Under these circumstances—without increased political support at state and local/regional levels—a wholeschool approach, although desirable, seems rather impossible to realize. However, many HPS programs are
based on such an approach, thereby demanding something unrealistic from schools. Our findings suggest that
schools try to do their best: supported by SPs, those interested in HP implement a wide range of activities, according to the current understanding and possibilities
existing within each school. Yet, if health and well-being
were integrated more deeply into the school system, the
collaboration between schools and SPs could potentially
be more fruitful.
ACKNOWLEDGEMENTS
The authors thank all study participants, as well as Rosemarie
Felder-Puig, Edith Flaschberger, Martina Nitsch and Friedrich
Teutsch for their contributions and helpful comments on this
paper.
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