AJHPE 207

Moving from conversation to commitment: Optimising school-based health promotion in the Western Cape, South Africa

F Waggie, BSc (PT), MSc (PT), PhD; N Laattoe, ACE (Adult Ed), MPhil Ed; G C Filies, BSc (OT), MPhil (Health ScEd)

Interdisciplinary Teaching and Learning Unit, Faculty of Community and Health Sciences, University of the Western Cape, South Africa

Corresponding author: F Waggie (fwaggie@uwc.ac.za)


Background. Recent evaluation of the Interdisciplinary Health Promotion (IHP) course offered by the University of the Western Cape (UWC) at schools revealed that the needs expressed by the schools had not changed in the last five years.

Objectives. This paper describes the process that was undertaken to identify specific interventions that would have an impact on the schools and, in turn, the broader community, and provides an overview of the interventions conducted in 2011 - 2012.

Methods. A stakeholder dialogue explored notions of partnership between the university and the schools, sustainability of health promotion programmes in the schools, and social responsiveness of the university. An action research design was followed using the nominal group technique to gain consensus among the stakeholders as to which interventions are needed, most appropriate and sustainable.

Results. A comprehensive plan of action for promoting health in schools was formulated and implemented based on the outcome of the stakeholder dialogue.

Conclusion. The study’s findings reiterate that an ongoing dialogue between schools and higher education institutions is imperative in building sustainable partnerships to respond to health promotion needs of the school community.

AJHPE 2013;5(1):26-29. DOI:10.7196/AJHPE.207


The notion of social responsiveness of higher education institutions is more than just maintaining contact with ‘clients’. It is about universities engaging in a dialogue with various stakeholders to learn more about the communities and how services are valued and implemented, and to encourage and initiate services that will contribute to the development of communities. Furthermore, it considers accountability by building mechanisms to incorporate transparency about all choices made and to assure the involvement of civil society.1 This article describes the process undertaken by the Interdisciplinary Teaching and Learning Unit (ITLU) in the Faculty of Community and Health Sciences (FCHS) at the University of the Western Cape (UWC) to identify specific health promotion programmes needed at schools, which would impact on the school and in turn the broader community more effectively.

Higher education and social responsiveness

Historically, there is a strong community service ethos in South African higher education institutions and most institutions identify community service as part of the universally recognised functions of the modern university, i.e. teaching, research and outreach.2 The South African Higher Education Act of 1997 emphasises the establishment of a single co-ordinated higher education system that responds to the needs of South African communities served by higher education institutions.3 Furthermore, the Act states that higher education ‘must provide education and training to develop skills and innovations necessary for national development and successful participation in the global economy and must be restructured to face the challenges of globalization’.3 Importantly, the Act also demands that new, flexible and appropriate curricula be developed to integrate knowledge with skills, and that the standards be defined in terms of learning outcomes and appropriate assessment procedures. This can best be achieved through community engagement and service learning.4 Moreover, given the extent of worldwide economic and social problems, and the current socio-economic climate in the country, there is an increasing pressure on South African higher education institutions to become socially responsive and bridge the gap between higher education and civil society. Braskamp and Wergin suggested that one of the ways for higher education institutions to narrow the gap between themselves and civil society is to ‘become active partners with parents, teachers, principals, community advocates, business leaders, community agencies, and general citizenry’.5 In line with these current imperatives, South African universities are engaging more closely with communities and developing a scholarly basis for such engagement by integrating the universities’ core business of teaching, research and service.6

A need for a different approach to health professions education has therefore emerged, one in which universities need to produce health professionals who are socially accountable and can respond effectively to the needs of the 21st century. The World Health Organization (WHO) defines social accountability of educational institutions as ‘the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve. The priority health concerns are to be identified by governments, healthcare organisations, health professionals, and the public.’7

Recently, the Lancet commission concluded that health professions education has not adapted to the ever-increasing health demands of communities and has produced ill-equipped graduates because of ‘fragmented, outdated and static’ curricula.8 Furthermore, the commission identified challenges for health professions education which included: (i) mismatch with societal needs; (ii) poor teamwork; (iii) weak leadership; (iv) predominant focus on tertiary care at the expense of primary healthcare; and (v) health professionals working in silos. The commission recommended that instructional and institutional reforms need to take place within the health professions educational system to address these challenges.

Response of the Faculty of Community and Health Sciences

The development of the Interdisciplinary Health Promotion (IHP) course was an innovative curricular transformation for health professions education at UWC. The course is based on the pedagogy of service learning and is one of the ways in which the FCHS responded to the aforementioned challenges. The purpose of the IHP was to equip the students with basic knowledge and skills of health promotion and apply these through the implementation of health promotion projects in schools. Recent thought in health promotion emphasises social change, environmental development, and development of capacities and opportunities for communities, and has the potential to support and sustain better health.9 , 10 However, the sustainability of improved health is dependent on the approaches, theoretical foundations, intentions and outcomes of health promotion programmes. According to Sanders et al.,11 the need for comprehensive action focusing on the social determinants of health is well overdue, particularly in sub-Saharan countries. This implies that health professionals need a solid understanding of the social factors which influence health, the experiences and needs of communities, and the challenge of partnerships and collaborative practice.

Since the inception of the IHP in 2001, health promotion theory has been applied in a particular setting, i.e. primary schools in ‘disadvantaged’ communities. Students are expected to plan, implement and evaluate health promotion projects in the schools. Theory is taught on campus and the Health-Promoting Schools (HPS)12 approach is used to guide students in the application of their health promotion projects. A health promoting school constantly strengthens its capacity as a healthy setting for living, learning and working.13 At any one time there are nine schools involved in the programme. Each year an average of 360 students from the following health professional programmes participate in the course: social work, dietetics, occupational therapy, physiotherapy, and School of Natural Medicine, Dentistry and Oral Hygiene. Students are assigned to an interdisciplinary class of approximately 35 students. The academics are recruited from the disciplines involved in the course; on average there are nine interdisciplinary classes, each with an academic staff member. Supervisors are also recruited from within the university to facilitate student learning in the schools. Most of the student health promotion projects are aligned with the Life Orientation (LO) curriculum of the Western Cape Education Department (WCED), although there are projects that address broader issues impacting on the schools and learners. These include abuse, violence, communicable diseases including HIV/AIDS, non-communicable diseases, life skills, hygiene, nutrition, citizenship, children’s rights, leadership, bullying, and drug abuse.

Problem statement

Annually, a document was published which contains summaries of the participating schools’ data and information pertaining to student projects, learner and educator numbers, number of classes, governing bodies, infrastructure, extramural activities, access to health and social services, and views of the educators on the health-promoting schools approach. The school information was collected by the ITLU staff and each school was afforded the opportunity to verify and rectify the information. Topics for student health promotion projects were provided by the co-ordinating educator at each school. During the editing and preparation of the 2009 document, it emerged that feedback and needs expressed by the schools had not changed since 2005. To address this dilemma, a stakeholder dialogue was organised to explore how the IHP course can impact on schools and the broader community more effectively.

Methods

An action-research design14 was employed, as it allowed the researchers to gain consensus among the stakeholders on how the course can impact on schools and the broader community more effectively, and to develop an intervention collectively with the stakeholders. The participants of the study included the following stakeholders who were involved in the IHP: (i) school community: the principals, educators and parents; (ii) faculty staff: academics and supervisors; (iii) service providers: school nurses and non-government organisations; and (iv) community health forum members. Data were collected using the nominal group technique15 to gain consensus among the stakeholders on how the course can impact on the school and the broader community.

Procedure and analysis

All stakeholders involved in health promotion in the schools where the IHP is offered were invited to a dialogue held on 18 October 2010 at UWC. Tables were set up in a group work format to represent each of the nine schools involved. The participants were asked to align themselves with their particular school, resulting in a good representation of the stakeholders working in that particular school. The moderator discussed the importance of dialogue, the participants’ contribution and how the outcomes of the stakeholder dialogue would be used. The findings of the annual school information, highlighting the problems, were presented. The groups were then introduced to a question: ‘What are the challenges experienced in the school?’. The participants had to consider the question individually and then their ideas were captured on a flip chart. A plenary session followed, where each recorded idea was discussed to determine clarity and importance. The moderator then facilitated a consensual process where the ideas were prioritised and recorded. The five action areas of the HPS were used as a guide to categorise the challenges raised by the schools (Table 1).

Using the same process, the participants were then asked to return to their groups and the following questions were posed: ‘What is possible, how can we use our limited time and resources more creatively? How do we begin to impact the school and broader community more effectively?’ A plenary session followed where the interventions required at the various schools were recorded by the moderator (Table 1).

Table 1. Challenges identified at participating schools

Components of HPS

Challenges at schools

Develop healthy school policies that will assist the school community in constantly addressing its health needs

Schools do not have policies for health promotion; these are therefore required

Development of the school as a supportive environment for the development of health attitudes and practices

Ignorance within families regarding health issues

Discipline problems among learners

Rampant social problems, such as abuse and violence experienced by learners and community

Lack of sustainable health promotion programmes

Lack of commitment of stakeholders

Community action that involves the school and broader community in taking ownership of and seeking ways to address their collective health needs by accessing resources for health

Ownership of health promotion programme by the school community is required

Poverty alleviation projects to be initiated by the school community, as poverty is experienced by the majority of learners

Awareness, support and educational activities to reduce early sexual activity among learners

Development of personal skills of members of the school community, thus enabling them to improve their own health and influence the health of others

Parental and community involvement is needed. Parents require motivation and skills to identify, initiate and lead projects in the schools and community

Generally low level of literacy among learners and community

Shortage of trained educators to initiate or assist with implementing a health promotion programme at the school

Management skills required for school governing bodies

An understanding of the ‘health promoting school’ concept is needed by the school community

Access to appropriate services to address the health needs of the school community

Schools not currently benefiting from the school feeding scheme should be referred to it to alleviate the problem of under-nutrition among learners

A general lack of resources and infrastructure in schools

Too few visits from school nurses and other health professionals

Intersectoral collaboration between the Department of Education, Department of Health and the non-governmental sector is required. While all of these agencies offer services in the schools, there is no collaboration

No access to appropriate service providers

No proper referral systems for vulnerable or sick learners

Safe rooms are needed at all the schools

HPS – Health-Promoting Schools


Results

The challenges put forward by the groups were categorised according to the components of the HPS, as illustrated in Table 1.

Table 2 represents the interventions needed at specific schools as expressed by the various stakeholders. Programmes that address teacher support and classroom management were stated as a priority for all the schools. Four schools listed the need for sport enhancement programmes, and staff development programmes were needed at three schools. Programmes focusing on literacy, counselling, motivational talks and parental involvement were mentioned by two schools. The following programmes were needed by individual schools: numeracy, coping skills, conducting a learner profile, evaluation of a feeding scheme, and the identification of at-risk learners.

To address the needs illustrated above, the following three recommendations were made by the stakeholders:

• A strategic planning session should be held with each school, stakeholders and community members to explore a vision for promoting health and to develop an action plan within the current limitations and constraints of the university and the school.

• The health promotion projects of the university students conducted in the school should address broader issues of the school and not only those identified in the LO curriculum.

• All stakeholders including the community members must be included in the design and delivery of the IHP.


Health promotion programmes 2011 - 2012

In line with the recommendations of the stakeholders, the following programmes were implemented by the staff in the ITLU in collaboration with various UWC departments.

Exploring a vision for health promotion in schools

Presentations were done by ITLU staff either with the entire educator body or with key educators in schools, mandated to drive health promotion programmes. Workshops were also convened on campus to encourage relationship building with principals and educators. These focused on promoting health in schools utilising the HPS, and educators and principals were also encouraged to share challenges, solutions and experiences with one another.

Health promotion projects to address broader issues in schools

Student projects included gathering information for the evaluation of feeding schemes, and students also developed projects to enhance sport in schools. In addition, ITLU community engagement activities contributed towards relationship building through staff development workshops. These workshops focused on teacher support and classroom management. A principals’ forum was initiated, which was facilitated by ITLU staff. The forum included school social workers and circuit management from WCED. Furthermore, ITLU notified other departments within the faculty and university of the interventions identified at the stakeholder dialogue. Consequently, a collaboration was established with the Interdisciplinary Centre of Excellence in Sport Science and Development (ICESSD) at UWC, which included educators and community members linked to the respective schools in funded, accredited courses. The course was followed by a conference and sports day where educators were afforded the opportunity to network and engage with a broad range of stakeholders actively involved in sport services in schools. An opportunity was also afforded to a community member linked to a school to attend an accredited and funded course on substance abuse offered by the Community Engagement Unit at UWC. Further collaboration has seen the formalisation of a programme with the Centre for Student Support Services (Leadership and Social Responsibility Unit) in which students addressed a vast range of issues such as numeracy and literacy in schools through participative programmes with the learners. Schools were also invited to join the HPS forum hosted by the School of Public Health.

Inclusion of stakeholders and community members in the design and delivery of the IHP course

The ITLU staff visited schools to present an overview of the course and discuss course content. Subsequently, a planning meeting was held where it was agreed by the educators that their role in the success of student learning is vital and that they will be more active in guiding the students during the classroom-based activities. Educators also requested follow-up sessions for further information about the content of the course. Students were engaged in a Look, Listen and Learn activity in which they went on a walkabout on the school grounds and in the surrounding communities. This was conducted by both educators and community members, who were also invited to participate in a health promotion course offered by the ITLU to facilitate a better understanding of health promotion in schools. Twelve educators participated in the course during the September school holiday.

Conclusion

In line with Brennan’s1 notion of social responsiveness in higher education, the process of engaging with civil society commenced with the stakeholder dialogue. On reflection, this proved to be a key contributing factor in the successes achieved thus far, as it allowed the university to learn more about the communities and the needs of stakeholders. In addition, the process has allowed stakeholders to be guided by various health promotion approaches appropriate to the specific interventions as identified by the schools. The first and second stages of the action research process revealed that, despite the successes achieved, promoting health in schools faces many challenges; however, the foundations have been laid for on-going dialogue. A key lesson learnt is that the importance of building strong partnerships should not be underestimated and that the time and activities required cannot necessarily be anticipated. Measurement of impact implies a longer-term process; therefore, this ongoing process will be monitored and evaluated periodically with an impact evaluation planned after 2015.

Acknowledgements. The authors thank the participating schools and all participants of the stakeholder dialogue. Furthermore, the authors wish to acknowledge the academics and supervisors for their contribution to the success of the course, Ms Jill Ryan, research assistant and Mrs Cornelia Fester, the administrator.

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