Making every school a health-promoting school

In the past year, the effect of the COVID-19 pandemic on schools has reinforced the profound links between children's health, wellbeing, and learning. In addition to deleterious effects on student engagement, learning outcomes, and educational transitions, there is growing evidence of the impact of school closures on children's and adolescents' emotional distress and mental health.¹ There are also concerns that students with mental health disorders are at greater risk of permanently disengaging from education, negatively affecting their future earning potential. Social inequalities risk being similarly compounded in other contexts, with growing fears that family socioeconomic pressures are contributing to students not returning to school due to pressures to work or marry. At no other time has there been such an appreciation of the value of schools as sites for academic and social learning, and settings that can enhance student health and wellbeing.

In 1986, the Ottawa Charter for Health Promotion provided a context for schools to be conceived as communities for creating empowered, engaged, and healthy students who are connected to families and local neighbourhoods. Consistent with this, in 1995 WHO conceptualised a health-promoting school as “a school that is constantly strengthening its capacity as a healthy setting for living, learning and working”.² Other frameworks and terms, such as comprehensive school health and healthy school communities, share the essential features of health-promoting schools—namely, that these frameworks and terms extend the delivery of a health education curriculum, or a discrete health intervention or programme (including a health service), to encompass the whole school curriculum and the broader ethos and environment of the school in ways that intentionally engage parents, carers, families, and the wider local community.³ These whole-school approaches have been shown to have clear benefits for learning, health, and wellbeing.3, 4, 5, 6

However, there are huge gaps between the ideal of health-promoting schools and current practices.⁷ Even where health-promoting schools are most embedded, health promotion initiatives are too often led by passionate teachers or committed schools without adequate resourcing. In this context, initiatives are rarely sustained beyond the interest of an individual teacher or school and, without government policy or education authority support, cannot be taken to scale. In the same way, although many health professionals or community-based non-governmental organisations have led remarkable programmes in schools in response to specific health issues, these programmes do not necessarily address the most essential health concerns and their antecedents, and too often fail to achieve the potential benefits that could accrue when specific programmes are aligned with a school's broader curriculum.

These standards charge the education sector with the primary responsibility for implementation (figure ). For only one of the eight standards (school health services) does the health sector appear explicitly responsible. Yet, in every country and school, engagement by the health sector will be required to shape each of these standards into a functioning health-promoting system that places student engagement and learning, as well as health and wellbeing, at the centre. Rather than dividing responsibilities, the health and education sectors will need to collaborate, deeply, to implement these standards. Arguably, this collaboration is the greatest challenge facing health-promoting schools because health and education sectors have historically been built from—and remain driven by—different fundamentals.⁷ Investing in a new workforce that can understand the context of both sectors is urgently needed.

Figure.

Global Standards for Health-Promoting Schools and Systems⁸

The eight standards relate to one another to collectively comprise a health-promoting system, with an emphasis on governance.

WHO is currently redesigning the Global School Health Policy and Practices Survey. To be completed by school leaders, the revised survey will enable evidence to be gathered for some of the indicators that accompany the Global Standards and, thus, will be a resource to assist national and global efforts to monitor progress towards implementation. Beyond school leaders, it is ultimately the student body that should also be surveyed because they are in the best position to judge what matters for school engagement, health, or wellbeing, such as the extent of bullying, the emotional support provided by teachers, the extent of participatory learning practices, the relevance of sexuality education, or the cleanliness of toilets. The wider context is that, beyond standardised academic assessment, routine measurement of student health and wellbeing is also required by countries to ensure that the health-promoting actions taken within schools match the health, wellbeing, and nutrition needs of students. Developing a comprehensive monitoring and evaluation framework for both education and health outcomes equally needs collaboration between the sectors.

Before the pandemic, especially in low-income and middle-income countries, some governments and schools might have been challenged by the concept of health-promoting schools, which extends the vision for schools beyond their traditional focus on reading, writing, and arithmetic, to embrace the wider skills required by young people to thrive in the 21st century. Furthermore, education systems in different countries invariably face resourcing challenges and differential pedagogical capabilities; leadership will be required by governments, schools, and communities. However, an expected result of school closures is that the more overt interactions seen between young peoples' engagement, learning, health, and wellbeing will equally have primed school communities to embrace the aspiration of WHO and UNESCO to “make every school a health-promoting school”.8, 9

We received grants from WHO to undertake the series of academic activities that led to the two reports.