Draft March 31-08
Monitoring and Reporting on Key Health, Learning and Program Indicators
in School Health Promotion: A Joint Statement from Canada’s Non-Governmental
Organizations
Note: The first seven pages of this document are meant to form the basis of a joint statement by
several non-governmental organizations in Canada. The remainder of the document is presented
here for background purposes. Participants in the national consultation on this document will
have the opportunity to comment on this draft at a workshop at the 2008 national school health
conference, through an email consultation or within a wiki situated at:
http://draftshpapers.wetpaint.com/page/School+Health+Indicators
There is an accompanying document that lists, in considerable detail, many of the Indicators of
capacity, implementation and specific health topics that should be covered a comprehensive
Monitoring and Reporting system.
This paper has been funded by the Health & Learning Knowledge Centre of the Canadian Council on Learning.
Introduction:
Regular monitoring and reporting of key health, learning and policy/program and other
indicators that truly reflect meaningful progress being made in health, health learning and system
practices is one of several essential system capacities required for effective school health
promotion. If there is no regular, reliable way to report to the public, policy-makers, parents and
stakeholders, it is more likely that the school, public health and other systems will be subject to:

unrealistic demands that schools fix all of the health and social problems challenging
youth

sporadic and sudden changes in priorities as politicians and system administrators
respond to the latest health news in the media or emerging public concerns

quick fix responses that seek to take an issue off the political/public agenda rather than
seek long term and realistic solutions

continuing pre-occupation with single health and social problems rather than the overall
health and well-being of the child

unrealistic policy-maker demands for simplistic, life-long outcomes rather than regular
reporting of contextual, input and process factors that lead to realistic outputs measurable
at the end of primary and secondary schooling
Canada is making progress towards a Pan-Canadian (ie a national method respecting local,
provincial-territorial and federal roles) system for monitoring and reporting on child/youth
health, learning and program capacity at all levels. Recent improvements include:

FPT task force work on monitoring chronic and infectious diseases (PHAC/HC)

Intergovernmental and inter-ministry are cooperating more in sharing and analyzing
data as a result of a joint HLKC-JCSH project.

University-based development of school self-assessment tools in safety, tobacco,
physical activity, nutrition (eg. Waterloo, York/Queen’s)

An initial analysis of the impact of health literacy levels among adult Canadians has
been done (CCL) and a expert panel will be identifying policy options (CPHA-HLKC)

UNESCO has published a paper on health literacy. The Council of Ministers of
Education, Canada is working on literacy overall which could include health. The
provincial superintendents associations are also working on literacy, thereby creating an
additional opportunity.

An analysis (Stevens, 2006) of current data sources and options for moving forward has
been published (HLKC). In particular, this analysis noted that by extending the use of
optional components of the Canadian Community Health Survey, a greater amount of
regional and multi-topic data could become available.

Synthesis reports by national agencies (CPHI) and at least two provinces (QC, AB)

A consolidation of provincial/territorial surveys on topics such as substance abuse is
underway through the leadership of CCSA and others.

Greater attention from the media is now looking for regular reports on school health
program status (eg The Globe & Mail is cooperating with CASH on a series of reports)

Innovations in some jurisdictions to include health and social development issues in
their mandatory school improvement/reporting programs (NF, QC)

Innovations in many local school boards, health authorities to use data from national
surveys such as the Canadian Community Health Survey that offers modules covering
most of the health challenges facing youth
However, several challenges remain, including:

A piece-meal, crisis driven approach to collecting data on the health and well-being of
children by health systems that responds only to the latest emerging health or social
problem rather than a holistic view of the whole child and the 20+ health and social
issues that should be addressed in a planned, sequential manner

A reluctance from the education sector to monitor and report on health and social
development learning in areas such as basic health literacy/essential social responsibility
among all students as well as optimal health and social development for most graduates
and vocational preparation/exploration for health careers despite the fact that such
curricula and learning is defined as mandatory for most grades

Difficulties in collecting and sharing data from several systems who are responsible for
delivering school health programs thereby resulting in reports narrowly focused on the
front line (usually only schools/educators) rather than on the systems overall

Confusion among many agencies who believe wrongly that monitoring and reporting can
be done adequately by developing self-assessment tools and hoping that busy, pre2
occupied schools will somehow pick them up and use them in their yearly planning

Continuing plethora of one time studies and surveys that are disconnected from viable
methods to place their results in front of policy-makers and decision-makers who have
the authority to modify programs and policies as well as disconnected from on-going
research and evaluation programs that can place such studies into an appropriate context

Insufficient capacity to analyze data from regular surveys in order to identify program
and policy implications and then to translate those implications into practical advice

Unnecessary restrictions on access to data collected by Statistics Canada (beyond
protections of privacy) or by universities (seeking to control publishing based on the
results)

A lack of government investment at all levels in collecting and analyzing meaningful data
because of the ongoing cost implications that is often seen as a problem in short term
financial planning within departments and ministries.

Current data collection systems do not adequately reflect, nor are they useful to rural,
geographically isolated communities

Current monitoring and reporting systems are not culturally relevany to aboriginal
communities and often do not collect data on relevant issues of more urgent concern to
those aboriginal children & youth
Action Recommendations (Draft)
The following organizations (to be listed at the end of this statement) have reviewed these
opportunities and challenges as well as the evidence presented in the discussion paper that
follows. These organizations have endorsed the key points noted herein about school health
program monitoring and reporting as a joint consensus statement. These organizations believe
that those principles and practices will lead to improvements for Canadian children and youth
through more effective school health programs. Further, the undersigned organizations hereby
call upon the following agencies and organizations to act as follows:
1. The Council of Health Ministers should develop an overall, multi-year plan to monitor and
report on the health status and behaviours of children and youth as well as the factors that affect
their health. This plan should address all of the health and social problems that challenge youth
and reflect the evidence and key points outlined in this paper.
2. The Council of Ministers of Education, Canada should develop an overall plan for monitoring
and reporting on basic health matters as part of its national initiative on literacy. Further, its PanCanadian Assessment Program should include health and social development as a core
component so as to report on the health/social learning and vocational preparation for health
careers being achieved by Canadian students relative to other jurisdictions such as the United
States, Australia and Europe.
3. The Canadian Institutes for Health Research should develop a capacity and funding stream for
projects that will report on the health promoting status and capacity of settings such as schools,
work places and communities as an extension of earlier multi-institute work on the impact of
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physical and social environments. This work should be done in cooperation with agencies such
as the Social Sciences and Humanities Research Council.
4. Knowledge organizations such as the Canadian Council on Learning and its knowledge
centres, the Canadian Institute for Health Information and its Canadian Population Health
Initiative should allocate funds from within their strategic funds to assist in developing a
evidence-based School Health Monitoring and Reporting System.
5. National organizations, professions, university centres and independent organizations should
work with local agencies and the media to develop an ongoing method to report on the overall
status and issues affecting school health promotion. This should include a series of reports on
the capacity of schools/professionals, local school boards/agencies and government
ministries/departments that will be done on various health/social issues and aspects of school
health promotion. These reports will emphasize the impact of local context and systems
capacities as a determining factor to success and sustainability, and will not compare
provinces/territories in superficial ways.
6. Researchers should work with non-governmental organizations and others associated with
each health and social issue of relevance to children and youth to articulate key outputs at the
end of elementary and at the end of secondary schooling.
7. (Others to be added)
Key Points about Evidence-based Monitoring/Reporting and Indicators in
National/State/Provincial Monitoring and Reporting Systems
1. Monitoring and reporting systems are a key part of system capacity in school health
promotion at all levels in several public service systems. They should be planned,
implemented and evaluated for the long-term by elected and appointed officials in
government and local agencies after extensive consultations with parents, community
representatives and professionals and in conjunction with expert advice and practitioner
feedback.
2. Indicators are carefully selected proxies chosen because they meaningfully reflect
significant contextual, individual, system or other factors that will affect the delivery of
public service programs as well as the health, educational and social development outputs
and outcomes of such programs.
3. In order to be significant, such Indicators must use data sources that are regular, reliable
and comparable over time and across similar contexts, systems and programs.
4. Data sources for monitoring and reporting systems can include administrative or program
data, regular tracking of cohorts of children, staff or events, surveys of the health
behaviours, knowledge, skills, attitudes, perceptions, practices of students, staff, parents,
community agencies, the general public and other people, surveys of the status of
policies, programs and practices at several levels in several systems as well as written and
oral and other tests of health basic literacy, knowledge, skills and intended personal
health action plans or intentions.
Other data sources such as one time or sporadic surveys, self-assessment tools used by
self-selected samples or subjects, environmental scans and groupings of similar studies or
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reports on individual programs into synthesis reports are useful in assessing system goals,
developing plans and determining readiness but should not be considered as a substitute
for effective monitoring and reporting.
Similarly, while program evaluation may draw from similar data sources, this activity is
quite different than monitoring and reporting systems.
Further, secondary data analysis is also desirable and part of effective knowledge
development and exchange but does not constitute an adequate replacement for
monitoring of school health promotion programs and reporting progress to the public and
policy-makers.
Finally, ad-hoc data collection and one-time reports do not constitute a monitoring and
reporting system, nor a set of Indicators. Often data is collected through surveys and
studies by researchers and government departments without a plan as to how and when
the results will go before decision-makers in systems or be fed into an on-going research
program with capacity to analyze and disseminate the findings as well as translate them
into policy and program implications. While such data collection may be useful for
primary research purposes, it does not substitute for a planned monitoring/reporting
system.
5. Monitoring and reporting systems, and consequently Indicators and accompanying data
sources should be established for all levels in health, education and other systems that
deliver school health programs. These include:
- School/neighbourhood/local professional level
- School board/health authority/other agency level
- State/provincial/regional health, education and other ministries as well as research
funding agencies, colleges/universities and other agencies
- national government departments and research, knowledge exchange and other
agencies
- international organizations and agencies mandated by governments to report on
global trends and to deliver global programs and services
6. Regular reports of the results of monitoring activities should be made at a variety of
levels and in a variety of formats, including
- regular reports on school health programs in education and health ministry annual
reports
- regular reports of school boards and local health authorities and other agencies
- regular reports on school improvement and effectiveness plans
Further, there should be regular reports and analyses on child/youth health, health
education and literacy and the status of school health programs from a variety of
independent and non-governmental agencies. As well, researchers should be encouraged
to analyze data sources to analyze and compare reports over time and with similar
contexts.
7. Monitoring and reporting systems should be based on an evidenced-based logic model
that explains why certain data/indicators have been selected.
The logic model for school health promotion has often been wrongly been placed on a
linear, single health issue model that seeks to control an intervention or set of selected
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interventions to achieve a desirable long-term outcome.
More recently, the need for coordination of multiple programs and interventions has been
recognized but little attempt has been made to adapt monitoring and reporting systems to
monitor whether such coordination is taking place.
Similarly, the evidence that there are clusters of negative and positive factors and
behaviours has not been reflected in SH monitoring and reporting systems. As well, the
impact of context has not been incorporated, despite occasional rhetoric to the contrary.
Moreover, new evidence about building system and agency capacity to sustain programs
as well as new strategies such as integrating health/social concerns with the educational
mandate and constraints of schools or with fairly obvious systems characteristics such as
loose coupling, openness to external influence and bureaucratic decision-making is not
reflected in school health monitoring/reporting practices.
8. The Indicators selected for school health programs should be based on:
- An ecological and systems-based approach
- Monitoring of the whole child, not just selected body parts or behaviours
- The whole school, not just instruction in the classroom
- The whole community, including parents and families as well as neighbourhood
norms and resources as well as relevant societal factors such as the practices of the
private sector, organized religion, political parties and governments, the new
media and more.
- Monitoring of relevant policies, programs and services delivered by other
agencies through or with the school
- A whole systems approach and not just the front-end of such systems such as
schools or teachers or nurses
- A recognition that while education and schools can be held more accountable for
health education and learning outputs, the health and development of the child is
shaped primarily by parents, families, peers and the media than by schools.
9. The monitoring and reporting system should be tied directly to the intended goals of the
system or organization being monitored. Indicators should also report on the achievement
of certain stated values of the systems. Consequently, if the stated goals included ideals
such as healthy living, democracy, equity and participation, then explicit data sources and
indicators should report on those outputs and outcomes.
10. The health and development of children is a shared responsibility among parents, social
institutions and public service systems such as health, social welfare, employment, law
enforcement, sports and recreation and others. Consequently, monitoring and reporting
on school health programs should be developed parallel to similar M&R for non-school
aspects of those other systems.
11. Indicators used in monitoring and reporting systems should be developed in these areas:
Context (Broad social, economic, political, technological factors at a national, state or
global level at the country level as well as local community context such as rural, urban,
religious, aboriginal, multiethnic etc)
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Inputs (Including capacities of children entering school, characteristics and expectations
of parents/families, staffing, school size, neighbourhood cohesiveness and resources, etc
Processes (Programs, Services, Policies, Practices, Structures and long tem capacities to
sustain these)
Outputs: (After five years of delivering programs - Changes to children and adolescents
after elementary school and secondary schooling to selected aspects of health status,
realistic and specific improvements in health/social behaviours and health/social problem
incidents, health literacy/knowledge, skills, attitudes/beliefs, personal health plans, and
changes to education, health and other systems regarding institutionalization of the SH
programs)
Outcomes: Five years after completion of programs and taking into account changes in
the intervening five years, examination of age-appropriate changes to young adult (not
life-long) health behaviours, health literacy/knowledge-skills and health careers choices,
and changes to policies and programs in post-secondary, workplace and recreational
settings in which young adults congregate.
The reports made to the public, practitioners and decision-makers should always include
these different types of indicator data, lest we encourage them to seek simplistic solutions
to complex problems.
12. Monitoring and reporting should not always be focused on deficits and negative
behaviours or avoidance of diseases or social problems. Indicators and data sources
should also report on strengths, assets and positive and protective factors.
13. Specific indicators related to each of the over 20 health and social issues that challenge
youth should be developed and used in an age-appropriate way such that different stages
of development and transitions are monitored effectively.
14. (Others to be added)
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Background Discussion (Review of Research)
Monitoring, Reporting and Indicators of Progress in School Health Promotion
The purpose of this paper is to explain and illustrate the key points about monitoring and
reporting systems that have been articulated above.
Several Canadian reviews (Finlay, 2004; McCall, 2002; McCall et al, 1999; Shannon & McCall,
2001, 2002; Woodward e al, 2004) as well as international reviews (Allensworth et al, 1997,
Nutbean & St. Leger, 1997, WHO Expert Committee on School Health, 1997) have called for
regular information on professional and agency practices in public health and school health as
well as on health status/behaviours and on health literacy/knowledge of children and youth.
Monitoring and reporting in school health promotion should include regular, reliable and timely
collection and communication of data on:
 the health outcomes, social behaviours of children and youth, and their connectedness
to parents, schools and the community
 the basic health literacy of all students, achievement of optimal health knowledge,
skills and attitudes/beliefs for many students and the preparation of some students for
careers in health related careers
 the status and capacity of government ministries, local school board/health
authority/local agency and school/professional/neighbourhood policies, programs and
practices.
This discussion paper is intended to provide the background for the key points identified above.
It is a work in progress and all input is welcome. This paper is organized as follows:
A.
Valid, Evidence-based design of M&R and Indicator Systems
B.
Applications to School Health Promotion
C.
Measuring and Monitoring Complex Contexts
D.
Monitoring Programs, Coordination of Programs and Comprehensiveness
E.
Monitoring Capacity, Sustainability and Instititionalization with Education System
and with Key Characteristics of Loosely-Coupled, Open, Bureaucratic Systems
F.
A Composite, Non-linear, Ecological Logic Model for School Health Promotion in
Different Contexts
G.
A Preliminary Framework for Monitoring/Reporting of SH Programs in a High
Income Country such as Canada
A. Valid, Evidence-based Design of Monitoring/Reporting and Indicators Systems
A monitoring/reporting system, with carefully selected indicators based on reliable data is a tool
to focus system reform and improvement. The goals or intended benefits of implementing such
monitoring/reporting systems are, to assess the effectiveness and efficiency of education
enterprise, to improve education and to provide a mechanism for accountability. The major
purpose about indicators systems to provide enhanced information about education for improved
planning, policy, practice and decision-making. (Smith, WJ., et al,1994. p2)
However, Earl & Fullan (2003) describe one of the challenges associated with the use of data in
educational decision-making that will likely have an impact on attempts to strengthen data
sources and better monitoring of results in health promotion. They point out that governments in
8
several countries have used data only for accountability purposes, rather than using the data
primarily for improvement purposes. As a result, educators have grown wary of these externallyimposed provincial assessments of learning that are rarely useful to school or board level
decision-making that would lead to improvements.
Wilms & Gilbert (1991) also describe the valid and effective uses of monitoring/reporting/
indicator programs. They can, measure change over time in key areas; be used to construct
baseline surveys that take into account background information; help to monitor trends; and help
to evaluate the impact of a program.
Although M&R/Indicators systems can be helpful in program evaluation, they should only be
considered useful in describing general trends, changes or program impacts over time. Program
evaluations need much more specific information than what an Indicator system can provide.
Shavelson (1991a) discusses what Indicator systems cannot do. They should not be used to:
 Set goals and priorities (They should be considered as only one factor)
 Evaluate programs (Indicator systems do not substitute for specific data gathered about the
functioning of the organization or program)
 Develop a numeric balance sheet of outputs (Social Indicators don’t have a common referent
as do economic indicators which are based on financial considerations only).
Problems with Current Indicators Systems
Indicators that are devised without a clear overall concept and without a common frame of
reference are likely to produce a jumble of disconnected facts and figures. We should proceed
with the development of Indicators only after we have a model that that describes how the
system works. Indicators systems should be based on input/process/output models as well as
devoting a lot of attention to content (Delfen,1994, p.4).
Smith, et al. (1994, p.4) also tell us that current Indicator systems have:





A tendency to measure only outcomes rather than inputs and throughputs
A tendency to ignore context
Ignored implementation issues (educational differences, social, administrative and technical
problems, political and financial difficulties)
Failed to make the necessary correlation to effective schools research
Failed to show linkages to other systems and agencies.
Kaagan & Cohen (1989) also show how state education Indicators systems are too narrowly
defined in their scope and in what they measure.
Selecting Valid Indicators
The data sources that are eventually selected as an Indicator will tell us as much about who
wants what to be measured as the actual data that is being collected. They will reflect the values,
views and priorities of those developing the Indicators. Keep in mind that most Indicators are
only a proxy for the actual measurement we would like to make about the system.
Darling-Hammond & Ascher (1991) suggest that the following criteria be used to select
Indicators at the local community/school district level. They should be problem-oriented,
relevant to policy, reflective of educational outcomes, indicative of student backgrounds, and
9
illustrative of school content. They should also include consideration of how the data will be
interpreted. They also suggest that we should emphasize validity, reliability and complexity.
Further, Indicators should go beyond student test scores to reflect the student’s entire experience
with school.
Edmond (1992b), p.10), a school-district based researcher, provides a similar comprehensive and
practical analysis of education indicators. He states that Indicators should:
1.
2.
3.
4.
5.
6.
7.
8.
reflect central or core features of the educational system
provide information pertinent to current or potential problems
measure factors that policy can influence
measure observed behaviour rather than perceptions
use reliable measures
provide analytic linkages among the indications
be feasible to implement
address a broad range of audiences.
Building local evaluation capacity vs generalizable evaluation findings
Deccache (1997) suggests that greater consideration should be given to continuous quality
improvement rather than external standard inspection in addressing evaluation, effectiveness and
quality in health promotion. He argues for the use of a wider range of disciplines in health
promotion, than simply epidemiological (health status) or health behaviour change. He notes that
educational science has widened the definition or process to include both throughput and input.
He also suggests that anthropology can help us to see the broader picture, including both
intended and unintended outcomes. This helps us to better understand the impact (which includes
intermediate, direct and indirect, planned and not planned changes in perceptions and attitudes)
and results (which includes access and use of health services as well as changes in health status).
Need for a Vision and Logic Model
Warren (2005) suggests that risk factor surveillance in developed countries is often lacking a
vision or overview to guide its activities. His analysis is based on the Canadian experience,
describing the development, evaluation and current status of risk factor surveillance. He
describes a “patchwork quilt” of surveys, often if not usually carried out as single-issue, one-time
surveys. He suggests that one reason for this disjointed development is that health surveillance
Canada, unlike other countries such as the United States, has never had an institutional home.
He further suggests that the absence of a long-term vision to develop risk factor surveillance is a
barrier to further progress. He also notes that more effort needs to go into data analysis and
training of practitioners in data use.
Auer & Anderson (2001) also suggest that a long-term vision or framework is necessary to guide
the development of a framework for injury surveillance in Canadian aboriginal communities.
They also note that traditional surveillance systems, by virtue of their structure, promote a
disassociation between the information and community action. The framework developed by
Auer & Anderson places the locus of control with the community, in partnership with its data
sources.
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Effective Practices and Principles in Choosing Indicators
The following principles must be used to develop a valid framework for choosing reliable
Indicators.
a.
The Indicators selected should be directly related to the goals of the system(s)
being examined and be based on a coherent logic model describing the system and
the surrounding context.
b.
The social and economic context, as well as community and family characteristics,
should be measured and taken into account.
c.
The Indicators should describe and measure all of the relevant inputs into the
system(s).
d.
The processes that take place in the school, family, related agencies and the
community which have an impact on learning should be measured and described.
e.
The immediate outputs from the system(s) should be measured and described.
f.
The long-term outcomes of the system(s) should be measured and reported.
The Indicators Must Have a Direct Relationship to System Goals and Logic Model
The Indicators selected should be directly related to the goals of the system(s) being
examined. They should start with an examination of the “program logic” of the enterprise
to assess whether it is or continues to be valid for the constituency served. This would
include questions related to relevance of the system, underlying assumptions about the
system, the socio-economic conditions affecting the system and the stability of the data
sources from which the Indicators will be based. Further, they should also measure goals
for the system such as accessibility, equity, efficiency as well as student achievement.
This will inevitably lead to an examination of systems other than education that have an
impact on child health, learning and social development. Consequently, we must include
data that measures the activities of health and social services systems that serve children
and families. A preliminary framework for monitoring multiple systems is presented later
in this paper
Social, Economic and Community Context
The broad societal and economic context at the national and state/provincial level , as
well as community and family characteristics, should be measured and taken into
account. Context indicators can also be used to monitor schooling resources and
processes. They may also forestall educators’ tendency to narrow outcomes to look good.
They can also provide information about the particular conditions in which certain
outcomes are achieved.
Morgan (2002) makes the case for developing a relatively new set of Indicators for health
promoting schools that serve low income or disadvantaged communities. He notes that
SH programs have tended to serve middle class populations and communities and have
not truly addressed the needs of communities living ion the margins of society. He also
introduces the notion that school health programs should be more focused on the
development of social capital. If this were truly done in SH programs and approaches, a
different set of indicators would be selected than those traditionally focused on specific
health behaviours.
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Inputs into the School System
The Indicators should describe and measure all of the relevant inputs into the system(s).
These can be seen in two broad areas: readiness for school and societal support for
learning. Student readiness for school (OERI, 1991) would include the health status of
young children and families, poverty, the availability of pre-school programs, the
curriculum and instruction in the schools, and the characteristics of the school. Under
societal support for learning (NCES, 1991) would be: family support, community
support, cultural support, and informal support.
Processes Within the System
The processes that take place in the school, family, related agencies and the community
that have an impact on learning should be measured and described. Tesch (1991) has
developed a list of school-based Indicators, which includes: the autonomy of school-site
management, instructional leadership, staff stability, parental involvement, school-wide
recognition of academic success, maximized learning time, sense of community, clear
grades and high expectations, and order and discipline.
Immediate Outputs
The immediate outputs from the system(s) should be measured and described. We need to
specify what it is that we are seeking to assess.
Long-term Outcomes
The long-term outcomes of the system(s) should be measured and reported. These
measures should include: demographics and family composition, family income,
education, youth employment and finances, as well as health, social behaviours and
attitudes.
To conclude, any monitoring and reporting system that does not include a variation on these six
different types of indicators (Goals, Context, Inputs, Processes, Outputs and Outcomes) is not
evidence-based and therefore is a valid way to report on progress to policy-makers and the
general public.
B.
Applications to School Health Promotion
Monitoring and Reporting is an essential system capacity for effective school health promotion.
Several Canadian reviews (Finlay, 2004; McCall, 2002; McCall et al, 1999; Shannon & McCall,
2001, 2002; Woodward e al, 2004) as well as international reviews (Allensworth et al, 1997,
Nutbean & St. Leger, 1997, WHO Expert Committee on School Health, 1997) have called for
regular information on professional and agency practices in public health and school health as
well as on health status, knowledge and behaviours of children and youth.
Monitoring and reporting in school health promotion should include regular, reliable and timely
collection and communication of data on:

the health outcomes, social behaviours of children and youth, and their connectedness
to parents, schools and the community
12

the basic health literacy of all students, achievement of optimal health knowledge,
skills and attitudes/beliefs for many students and the preparation of some students for
careers in health related careers

the status and capacity of government ministries, local school board/health
authority/local agency and school/professional/neighbourhood policies, programs and
practices.
Developing a comprehensive approach to school health promotion means that schools need to
implement a variety of programs and policies. It is important that policy-makers are informed of
current school capacities and the status of these comprehensive approaches.
For example, in the United States, the School Health Policies and Program Study (Centers for
Disease Control, 2007) is administered periodically at the national level to monitor such
progress. From their data, measurements can be conducted in regards to particular issues or
elements of SH promotion.
The analysis done by Brener, et al. (2006) is an example of the value of such regular data
collection and analysis. Using the criteria from another quality assessment tool, the School
Health Index, the authors were able to assess the capacity of schools to perform in selected areas.
Another ongoing monitoring tools used in the United States is the School Health Education
Profile. This profile is used to monitor characteristics of instructional programs in middle and
secondary schools by surveying the lead health education teacher in a nationally representative
sample. Grunbaum, et al. (2000) report on the School Health Education Profile data collected
from 36 state surveys. The results show that 91% of schools in their states had a separate health
education curriculum. The survey also reports on the coverage of several topics within those
curricula. As well, the data reports on the presence of a lead teacher and the professional
qualifications of the health and physical education teachers. Decision-makers and program
developers in Canada are not provided the same quantity and quality of program data.
Austin, et al. (2006) have reported on a case study that used data and monitoring data to improve
school health programs. They compared the responses of nine public schools that used the
CDC’s School Health Index, a data collection tool that reports on the school policies and
programs. The schools that benefited from the help of an outside facilitator were able to
complete the Index in a collaborative way, to create action plans and to work as a team to
implement programs. Schools who collected the data but did not have a facilitator were not able
to accomplish these tasks.
Data collected on health education tests can guide policy-making as well as teacher training
programs. Tompkins, et al. (2005) developed a health literacy/knowledge student assessment tool
based on the U.S. standards for health education. They correlated their findings for the state of
West Virginia with the results of the national Youth Risk Behavior Survey – in order to
underscore the importance of such data. The data was used to plan a subsequent teacher-training
program.
Mitchell, et al. (1997) used regular assessments of progress as part of a planned surveillance and
monitoring program in their planning and implementation of their healthy school program in
Middlesex-London, Ontario. They used the School Health Index, a self-assessment tool for
schools, to show the impact of assigning staff or infrastructure to coordination.
13
In Canada. Stevens (2006) identified the current data sources available for tracking the health
and health learning of Canadian children and youth. This was part of a provincial/territorial
consultation undertaken by the intergovernmental Joint Consortium for School Health with
funding from the Health & Learning Knowledge Centre of the Canadian Council on Learning.
The report noted that the Canadian Community Health Survey included several optional
components that regional health authorities and provinces/territories could use to track the health
of Canadian young people. The value of this survey is that it contains regional data sets that can
be analyzed by health authorities and their corresponding school boards and other agencies.
C.
Measuring and Monitoring Complex Contexts
Section G of this paper presents a depiction of the non-linear, complex ecology of the school and
intervening systems as well as how the school environment interacts with the characteristics of
the individual child, families and neighbourhood. That section also presents a larger scale
diagram of how effective school health programs (based on eight principles or pillars) are
mediated and filtered by the differing contexts of countries and local communities.
These diagrams are quite different from the linear program models often used in program
planning and random controlled trials used to evaluate the effectiveness of individual programs.
It is suggested here that monitoring and reporting programs need to take this complexity and
various contexts into account. Further, we need more indicators selected to reflect these factors
which although complicated and confusing to the eye and brain, actually reflect the reality of
schools.
Steers & Parsons (2002) presented the arguments for using an eco-holistic model for
conceptualizing and evaluating health promoting schools programs at a conference on the
European Network of Health Promoting Schools. They noted that this eco-holistic model was
effective in predicting issues that would arise within the school as they sought to transform the
school ethos. They then go on to describe the types of Indicators that would reflect this approach:
14
Subsequently, Steers & Parson show how a new set of questions, not driven by medical minded
health issues, can be used to determine if the school is becoming more health promoting:
Ebbesen, et al. (2004) also present a number of strategies used in the heart health project to
overcome those measurement challenges. They include:

Managing and disseminating sensitive data

Acknowledging the context of the intervention

Incorporating mixed methods of evaluation

Building on previous phases of community engagement

Establishing the validity of qualitative measures by ensuring content, construct
validity and reliability

Establishing trust worthiness of qualitative data by triangulation, participatory
research processes, participant observations, member checks and peer debriefing,
prolonged engagement, using intervention-specific evaluations.
15
Moglia, et al. (2006) conducted a survey of school practices related to indoor air quality in the
United States. The survey asked questions about their use of a IAQ program and whether they
used a comprehensive program published by the Environmental Protection Agency. The quality
of the school practices was also compared by an index to describe the level of activity in the
school. Their results showed that 42% of U.S. schools have an IAH program and nearly half of
those schools used the EPA program. There has been a steady growth in the use of such
programs between 1988 and 2002, with participating schools reporting increased workplace
satisfaction, fewer asthma attacks, fewer visits to the school nurse and lower absenteeism. The
survey also showed that having a program did not necessarily mean that the practices of the
school were effective because implementation varied. This is the type of ongoing
monitoring/reporting that provides meaningful data to decision-makers.
Appreciative inquiry is a concept that can be integrated within the system capacity we have
called monitoring and reporting. Markova & Holland (2005) call this type of inquiry a strategy
for systemic change that builds on organizational strengths, not deficits.
For example, it seems relatively self-evident that emotional intelligence measures such as those
described in Conte (2005) would be used to measure and monitor implementation of school
health programs, specifically in regard to school principals, teachers and eventually, the students.
This review did not identify any such studies.
Sustainable capacity is another important consideration in developing a health risk factor
surveillance system. There is an urgent need to go beyond simply releasing the data and generate
useful, relevant and accessible information for decision-making. De Salazar (2005) has discussed
these issues, including the need to go beyond technical data collection issues, to consider
sustainability, usability and utilization of surveillance data. The issues include political will,
community involvement, decision-making processes and accountability. He suggests that
community-based surveillance strategies are more effective and sustainable. He presents the
vision strategies, methods, tools and results of such community-based data systems in monitoring
infectious diseases.
Warren (2005) continues this discussion of capacity in surveillance and suggests that a visiondriven approach for surveillance is needed. Working from his experience in working with Health
Canada, Warren notes that a vision-driven approach would start with the notion of how the data
will be used as the key first decision to be made.
Zubrick (2005) also discusses how health surveillance should be improved based on Australian
experiences. He suggests that there is too much focus on developers, users and stakeholders in
the data driven surveys. He suggests that more attention should be given to the relevance of the
data being collected and the pathway models of disease and health. He suggests that we should:
a.
Establish a shared theoretical basis for risk behaviour surveillance that extends beyond
health to include other disciplines such as education and social services.
b.
Deliver data about the health and development of individuals living in different
contexts over time.
c.
Maintain a systems approach to monitoring data that builds capacity for development,
ownership, access to data and dissemination of the data outside of the health system.
d.
Build sustainable partnerships that produce more inter-sectoral engagement over data.
16
D.
Monitoring Programs, Coordination of Programs and Comprehensiveness
Bauer, et al. (2003) report on the development of indicators to be used in a European Health
Promotion Monitoring System. This model used a systems-based approach as the rationale and
common frame of reference for the selection, organization and interpretation of the selected
indicators.
They created a socio-ecological model of health promotion that has used the five action areas in
the Ottawa Charter on Health Promotion to form five types of indicators. The paper then applied
this frame of reference of reference/indicator development to the workplace setting. This shows
that it is possible to use a systems-based approach in developing, monitoring and reporting
mechanisms for policies and programs.
Monitoring and reporting on school health promotion needs to account for and describe what is
going on at different levels in the environment and systems influencing that environment. An
example of this multi-level evaluation and monitoring can be found in the evaluation framework
done for the California Healthy Cities Project. In that settings-based strategy data is collected at
five levels: the individual, civic participation, organizational, inter-organizational and
community. Similar multi-level modeling needs to be developed for school health promotion.
Ringwalt et al (2002) have reported on the prevalence of evidence-based curricula in American
schools to prevent substance abuse. There was one similar study done over 15 years ago about
the use of evidence-based smoking prevention programs in Canada. Otherwise, this somewhat
basic information is usually not collected.
(More to be added)
E.
Monitoring Context, Capacity, Sustainability and Institutionalization with
Education System and with Key Characteristics of Loosely-Coupled, Open,
Bureaucratic Systems
New research on effective school health promotion programs suggests strongly that greater
attention needs to be paid to the impact of local context, system capacities and the key
characteristics of systems and organizations in order for these programs to be effective and
sustainable.
Consequently, monitoring and reporting systems and the indicators selected to populate those
systems should include data sources that report on these factors. A simple portrayal of these
factors is presented below and then followed by a generic and simple diagram of a logic model
for school health program monitoring/reporting.
17
Draft March 31-08
F.
A Composite, Non-linear, Ecological Logic Model for School Health Promotion in Different Contexts
These two diagrams depict the complex
ecology of the school and of the country and
community contexts that will affect the
delivery of school health programs through
and with schools. The realities of these
contexts must be captured in monitoring and
reporting programs through reliable and
meaningful indicators.
This ecological, systems-based model is
developed from a number of landmark and
recent reviews of school health promotion
research (Flay, 2002, McCall, 2004, Scheier
et al (2002) Bordi et al (2002) Alberta
Alcohol and Drug Abuse Commission
(2003) Berry (2002, Schneider (2002,
Connell, et al. (1985) , Patton, et al. (2006)
and Early (2004) have found impacts from
variety of school influences and programs.
A number of reviews (Lister-Sharp, et al.
(1999) West, et al. (2004)
World Health Organization (1997)
Allensworth, et al. (1997)
Nutbeam & St. Leger (1998)
Stewart-Brown (2006) have found that
comprehensive approaches, coordinated
programs and (whole school) health
promoting school strategies can improve
health and have some impacts on
educational achievement.
A Non-linear Logic Model for School Health Promotion
Health Promoting Schools, Coordinated School Health Programs, Comprehensive Approaches:
A Summary of Effective School Health Promotion that can be used to develop a Logic Model
The school is a place or setting within the community that can promote health, equity, social development & cohesion, safety and environmental
citizenship as well as focus on learning, educational achievement and school effectiveness. A health promoting school (and similar whole school
strategies such as safe schools, community schools and green schools) strives to have all facets of the school support the development of the whole
child through policy, instructional, social support, healthy physical environment and health/other services. Programs, policies and practices should
be delivered across these five domains and should be developed, implemented and evaluated in partnership with students, staff, parents, the
community, local agencies and professionals.
Coordinated school health programs that are implemented and supported at all levels in education, health and other systems are more effective
than single interventions or project activities. These programs need to be selected to match the local community context, whose needs and strengths
have been identified through data collection., regular monitoring and analysis. A comprehensive approach that addresses clusters of behaviours
and conditions and that uses synergistic combinations of programs is more effective.
Policy-makers, government and agency officials need to invest in long-term capacity building within professionals, schools, agencies and
communities to ensure sustainability. These capacities include the key functions of assigning staff and developing mechanisms to support
coordination at al levels and across several systems, knowledge exchange & workforce development, monitoring/reporting and overall coordinated
policy and leadership. Practitioners and researchers need to address the complex ecologies of schools and other organizations as well as the key
characteristics of open, loosely-coupled and bureaucratic systems that are engaged in school health promotion so that their efforts are more
strategic and enduring.
This knowledge about effective school health promotion can be further distilled into ten key points about safe, healthy, community and effective
schools that that can act as pillars for sustainable, effective action at all levels.
1.
2.
3.
4.
5.
Address the needs of the whole child, use a positive (assets, strengths,
resilience) approach over the life course
Serve all children, especially the disadvantaged and vulnerable
Understand, describe and explicitly address context
Strive towards comprehensive approaches (relevant clusters of issues,
multi-level & synergistic programs)
Select evidence-based programs &
6.
7.
8.
9.
10.
19
Implement using diffusions and innovations evidence as basis for planned
systems change
Coordinate SH programs (whole school, community & schools) using
policy, instruction, services, social and physical environment
Seek congruence with school education mandate and constraints
Build capacity at all levels (government, agencies schools, professionals)
Understand and strategically address system, community, professional
characteristics (open, loosely-coupled, bureaucratic)
Draft March 31-08
Non-Linear Complexity Model for School-based and School-Linked Promotion of Health, Equity, Social Development, Safety, Environmental Citizenship
Principles/Pillars for
Action
Whole child,
positive approach,
life course
2. All children,
especially
disadvantaged
3. Understand,
explicitly address
context
4. Strive towards
comprehensive
(relevant clusters
of issues, multilevel & synergistic
programs)
5. Evidence-based
programs
6. Evidence-based
implementation
7. Coordinated SH
programs (whole
school, community
& schools) using
policy, instruction,
services, social
and physical
environment
8. Seek congruence
with school
education
mandate
9. Build capacity at
all levels
10. Understand and
strategically
address system,
community,
professional
characteristics
(open, looselycoupled,
bureaucratic)
Country/
State/Provi
ncial
Context
and
Interactions
National,
state/provincial
governments,
ministries
---Research agencies,
universities,
colleges professions
NGO’s
Community/
Regional
Level
Context and
Interactions
Low income
urban slums
1.
Low Income
Countries
Governments should
seek to identify and
use external
resources to build
capacity
Researchers,
agencies, NGO’s seek
to innovate using
scarce, external
resources, them
exchange knowledge
High and
Middle
Income
Countries
Governments should
build system
capacities (policy,
coordination,
cooperation,
knowledge exchange,
workforce skills,
monitoring/reporting,
issue management,
sustainability)
Researchers,
professions, NGO;s
advocate and
develop/exchange
knowledge
Isolated rural
areas
Socially
isolated, high
income
communities
Ethnic,
religous
communities
Aboriginal
Communities
Suburban
communities
Inner city
slums
Rural, isolated
communities
Low income
communities
Ethnic,
religious
communities
Aboriginal
communities
School Board,
Health
Authority,
Police Dept,
Municipality
Other
Agencies
Local agencies
(if they exist)
should focus on
teacher training,
and in-service
for
professionals
and community
volunteers
Local agencies
should also
focus on
building
schools,
obtaining clean
water etc
School boards
and other
agencies
should build
school &
professional
capacity and
establish joint
plans, policies,
programs
School boards
and agencies
should help
schools and
neighbourhoods
to identify
priority issues
develop their
long-term plans
School/
Neighbourhood
Context and
Interactions
Programs to
recruit students
into schools in
isolated and
urban areas
Schools in
refugee camps
Parent/family
programs
School/
Classroom/
Professiona
l Level
Health,
educational
and social
outputs at
(Teachers,
nurses,
police, social
workers,
psychologists
, counselors
etc)
Kindergarten
Elementary
School
Junior High and
Senior High
Level
The school is
often the
centre of the
community
and acts as a
hub for
social, health
and
economic
programs.
Rural schools
Schools in poor
neighbourhoods
Schools serving
diverse
communities or
one ethnic,
religious group
Schools serving
aboriginal
students
Schools and
professionals
should select
the cluster of
issues,
synergistic
programs
and whole
school model
most
appropriate
to their
students
needs
(healthy
school, safe
school,
community
school etc)
Changes in
infant mortality,
adolescent
health, disease
rates etc.
School
participation
rates among
young people,
especially girls
Reductions in
disease or
malnutrition
Improvements
in basic health
literacy
Religious schools
Inner city schools
Affecting
Outputs and
Outcomes
Life-Ling
Health,
Social
Development
and
Educational
Outcomes,
Behaviours
(After one or two
years)
Private schools
Suburban
schools
Broad
Determinants
and Factors
and
Interactions
(After several
years of
programs)
Basic Health
Literacy,
Optimal Health
Knowledge/
Skills/Health
Careers
Age appropriate
Health
Behaviours
Status and
capacity of
programs and
policies
Economy
Employment
Crime
Physical and
social
resources
Media
Culture
Ideology
Societal norms
Gender
Race
Language
Place
Transportation
Technology
Pollution
Climate
Comparisons
to previous
generations or
longitudinal
studies that
track programs
over the life
course of the
people being
studied
Draft March 31-08
H.
A Preliminary Framework for Monitoring/Reporting of SH Programs in a High Income Country like Canada
This very preliminary framework can be the starting point for developing indicators in a effective monitoring and reporting system. The type and
nature of the issues that have more relevance to the various local community contexts. For example, low income communities might be primarily
concerned with run-down schools, gangs & guns, drug abuse and family violence whereas high income communities might be more concerned with
bullying, drinking & driving, youth alienation and families going through divorce. These differing as well as common issues need to be reflected in
M&R programs and especially the selection of relevant indicators
Draft March 31-08
Appendix One
List of Potential Indicators for School Health Programs
-
General Health/Growth & Development-Puberty;
Infectious Disease-Personal Hygiene;
First Aid;
Home Economics-Family Living Practices-Skills;
Child Abuse-Neglect;
Sexual Abuse of Children;
Vision-HearingGenetic-Birth Defects;
Parasites;
Physical Activity-Sports-Active Living-Recreation;
Healthy Eating-Nutrition-Obesity-Eating DisordersFood Security-Food Safety;
Injury Prevention;
Addictions-Alcohol-Drugs;
Tobacco Use;
Mental Health-Mental Illness-Suicide;
Sexual Health-HIV-AIDS-STI;
Bullying-Delinquency-Violence-Crime-Behaviour Disorders-ADHD;
Social Development & Skills-Responsibility-Civics-Service Learning-Relationships-SocialEmotional LearningSpirituality-Religious Beliefs;
Gender Equity;
Racism-Multicultural Awareness-Human rights-Diversity;
Ethics-Character-Personal Development-Decision-making-Critical Thinking;
Life Planning-Career PlanningSelf Esteem-Awareness;
Environmental Health-Allergies-Asthma-Lung Health;
Environmental Citizenship-Stewardship
There is also a need to monitor the factors or determinants that will affect these health and social
issues for different children and youth. These include:
- Social influences
- Economic conditions/employment
- Cultural/Ethnic
- Geographical
- Political
- Media (mass media and new media)
- Role of corporations/private sector
- Technological
- Gender
- Language
- Religion/Spirituality
- Race
- Social and Community Norms
- Community efficacy and cohesiveness
Appendix Two
Sample Identification of Local Community Contexts/ Clusters of Relevant Issues that should be
Used to Tailor MRI Programs
High-income countries, states/provinces have a diverse set of local communities and regions that
will essentially dictate the capacities of their schools to promote health, equity and social
development. These include these types of communities:
- Suburban communities
- Inner city slums
- Rural, isolated communities
- Low income communities
- Ethnic, religious communities
- Aboriginal communities
Each of these local communities will have different challenges and capacities that need to be
reflected in the monitoring and reporting systems. In particular, the indicators selected for these
systems need to be meaningful for those local contexts.
For example, the issues that face disadvantaged communities within high-income countries could
include these issues and programs:
-
school meal programs,
parent resource centres/parent education and support programs
community schools (where schools work closely with housing, police, social services),
after school programs,
head start/compensatory education programs (incl. continuation of pre-school programs)
achieving basic literacy and health literacy for all students
school-drop out prevention programs
substance abuse prevention
crime/violence and delinquency (more concern about gangs/ guns than bullying and less
violent anti-social behaviours
family violence and neglect
school renovations,
clean water, air quality,
basic housing
parasites such as head lice, vermin
racism and discrimination, immigrant settlement issues
safe transportation to and from school
Low-income countries also have diverse local communities as well. These include these
examples of communities:
- Poor urban slums
- Isolated rural areas
- Socially isolated, high-income communities
- Ethnic, religious communities
- Indigenous, aboriginal communities
The issues that are more likely relevant to school communities in this context include:
basic hygiene/infectious diseases and parasites,
HIV/AIDS/sexual health,
nutrition programs (including school feeding programs to attract students into school)
girls education
23
-
basic teacher training and qualifications
basic education/literacy and basic health literacy
school role in community economic development (eg agriculture, micro-businesses),
the role of corporations in development
the role of faith communities in development
affordable school construction, clean water, sanitation
24
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