Evaluating school effectiveness in health promotion

1. Evaluating school effectiveness in health promotion  An Victoir VCLB Vormingscentrum About the author: for 15 years, I have been a researcher at the Catholic University Leuven, where I obtained my PhD in health psychology. I studied health behaviours of school aged children and for that purpose I designed a tool to meausure health behaviours. I�ve always been working closely with school doctors, nurses, psychologists, pedagogues and social workers involved in health promotion and preventive health care. Today I�m going to talk about ways in which schools can evaluate if they are effective at health promotion.About the author: for 15 years, I have been a researcher at the Catholic University Leuven, where I obtained my PhD in health psychology. I studied health behaviours of school aged children and for that purpose I designed a tool to meausure health behaviours. I�ve always been working closely with school doctors, nurses, psychologists, pedagogues and social workers involved in health promotion and preventive health care. Today I�m going to talk about ways in which schools can evaluate if they are effective at health promotion.

3. The wish list We want children and adolescents� To love learning new stuff To find a school curriculum that matches their interests and capabilities To have a lust for life To be healthy and happy people I want to take you back to the basics. Why are we all involved in school effectiveness? Because we have a long wish list when it comes to kids. We would really like to see them grow up to be happy and healthy people.I want to take you back to the basics. Why are we all involved in school effectiveness? Because we have a long wish list when it comes to kids. We would really like to see them grow up to be happy and healthy people.

4. Making wishes come true What do we provide in the school setting? A high-standard curriculum Maths, history, languages, � Health education Life skills A protective social network A healthy environment Unfortunately, I am not Harry Potter and this ain�t Hogwarts. So we don�t have a magical wand with which we can make things happen. So, how can we contribute to children�s health and happiness from within the school setting? First and foremost, we aim to give them the best education possible. But we do much more. Our schools should also be a home away from home, a warm environment where children and adolescents feel at ease and can florish. We also make sure that our schools are safe and healthy environments. We make sure that playgrounds are safe, or that class rooms get aired during lunch breaks. Unfortunately, I am not Harry Potter and this ain�t Hogwarts. So we don�t have a magical wand with which we can make things happen. So, how can we contribute to children�s health and happiness from within the school setting? First and foremost, we aim to give them the best education possible. But we do much more. Our schools should also be a home away from home, a warm environment where children and adolescents feel at ease and can florish. We also make sure that our schools are safe and healthy environments. We make sure that playgrounds are safe, or that class rooms get aired during lunch breaks.

5. Health promotion at school? It is a great idea! Target group within reach Staff with expertise in Knowledge dissemination Skills training Parents count on us Government requires it from us Reduce smoking prevalence, obesity Tackle health inequalities Obviously, the times when school were merely institutions for teaching kids the 3 R�s (reading, riting and ritmatic) are long past. They have evolved to settings where young people develop as human beings, and that includes learning to adopt a healthy lifestyle. Most people think that schools are excellently suited to this purpose. You have to know a lot of stuff in order to do the healthy thing, and teachers are experts at knowledge dissemination and skills training. Parents expect schools to help them raise their children. Governments think that schools should contribute to healthy trends, such as a decrease in smoking prevalence.Obviously, the times when school were merely institutions for teaching kids the 3 R�s (reading, riting and ritmatic) are long past. They have evolved to settings where young people develop as human beings, and that includes learning to adopt a healthy lifestyle. Most people think that schools are excellently suited to this purpose. You have to know a lot of stuff in order to do the healthy thing, and teachers are experts at knowledge dissemination and skills training. Parents expect schools to help them raise their children. Governments think that schools should contribute to healthy trends, such as a decrease in smoking prevalence.

6. Health promotion at school? Are you nuts? Important antecedents of (ill) health are beyond reach Education and skills training Minor effects on health status or health behaviour Unless backed by major changes in other settings However, health experts have always warned us not to take too much in our stride. Whether you are healthy or not, depends on a lot of factors, and most of those factors are beyond the school�s reach. The thing that schools are best at, knowledge and skills training, has about the smallest effect on children�s lifestyle you can imagine.However, health experts have always warned us not to take too much in our stride. Whether you are healthy or not, depends on a lot of factors, and most of those factors are beyond the school�s reach. The thing that schools are best at, knowledge and skills training, has about the smallest effect on children�s lifestyle you can imagine.

7. Health promotion at school? A viable enterprise Provided Appropriate choice of outcomes Realistic expectations regarding magnitude of effects Efforts are matched in other settings (home, community, pre/after school care, sport clubs, �) Still, we are confident that health promotion at school is a viable enterprise. Otherwise we would not be sitting here today. But we are also cautious and realistic. Schools can have a good effect on pupil�s health provided We look at the right outcomes We have realistic expectations regarding the effects we can obtain at school We strive for similar efforts in other settings These are vital conditions in which to work and in which to evaluate school effectiveness. That is your first take-away message for today. Still, we are confident that health promotion at school is a viable enterprise. Otherwise we would not be sitting here today. But we are also cautious and realistic. Schools can have a good effect on pupil�s health provided We look at the right outcomes We have realistic expectations regarding the effects we can obtain at school We strive for similar efforts in other settings These are vital conditions in which to work and in which to evaluate school effectiveness. That is your first take-away message for today.

8. Outcomes Level 1: health status Holistic view Physical health Body Mass Index, hearing acuity, growth, � Psychological health Self esteem, identity, resilience, � Social health Altruism, friendships, assertiveness, � Apt term: �Wellbeing� Let�s take a look at the first prerequisite, working on appropriate outcomes. On the highest level, there is the health status of children. We know that health is a holistic concept. There is the physical or somatic component. For example, healthy children have a normal weight, have predictable growth spurts, and so forth Healthy children are happy with themselves. They know who they are and are proud of themselves. They bounce back in times of stress and crises. We know that many children and adolescents are not happy. For example, many homosexual and lesbian adolescents have a tough time coming to grips with their sexual orientation and identity and in that group the risk of suicide is elevated. Healthy children bond in a positive way with their social environment. They have a close circle of friends. They also have the skills to bicker and argue, because falling out with each other is normal and healthy side of social interactions. Let�s take a look at the first prerequisite, working on appropriate outcomes. On the highest level, there is the health status of children. We know that health is a holistic concept. There is the physical or somatic component. For example, healthy children have a normal weight, have predictable growth spurts, and so forth Healthy children are happy with themselves. They know who they are and are proud of themselves. They bounce back in times of stress and crises. We know that many children and adolescents are not happy. For example, many homosexual and lesbian adolescents have a tough time coming to grips with their sexual orientation and identity and in that group the risk of suicide is elevated. Healthy children bond in a positive way with their social environment. They have a close circle of friends. They also have the skills to bicker and argue, because falling out with each other is normal and healthy side of social interactions.

9. Outcomes Level 2: determinants of health Environmental factors Waste disposal, drinking water, housing, � Access to health care Personal factors Age Genetic endowment Personality (anxiety, optimism, �) Lifestyle (physical activity, diet, substance use, �) One level down we find factors that lead to good or ill health. Some factors are situated in the environment. We enjoy good health because our tap water is drinkable and because municipalities pick up our garbage. In western Europe access to health care is excellent. Other determinants of health are situated within persons. Your mum and dad did not just provide you with genes that made your eyes blue or brown, but they also passed genetic mistakes which may increase your chance of developing diabetes. Our personality can also make us happy or unhappy. If you�re a Type A personality, you always feel like there is too little time to do the stuff you want to do and that makes you unhappy and prone to coronary disease! Last but not least, health related behaviours are very important determinants of health status.One level down we find factors that lead to good or ill health. Some factors are situated in the environment. We enjoy good health because our tap water is drinkable and because municipalities pick up our garbage. In western Europe access to health care is excellent. Other determinants of health are situated within persons. Your mum and dad did not just provide you with genes that made your eyes blue or brown, but they also passed genetic mistakes which may increase your chance of developing diabetes. Our personality can also make us happy or unhappy. If you�re a Type A personality, you always feel like there is too little time to do the stuff you want to do and that makes you unhappy and prone to coronary disease! Last but not least, health related behaviours are very important determinants of health status.

10. Outcomes Level 3: health behaviour determinants Within the person Cognitive = What I know Affective = What I feel Motivational = What I want Skills Within the micro-environment Availability of (un)healthy products Cues that elicit (un)healthy behaviour So, let�s look at these health behaviours. Why do young people smoke? And why do so many of them take up sports? Youngsters do things because of what�s in their head: knowledge, feelings, intentions, and perceptions of skills determine whether or not they take up healthy habits. But young people also act in response to their environment. You can�t do the healthy thing, if healthy products or services are not available. And often, we uncounsciously do things because a cue in the environment elicited a particular behaviour.So, let�s look at these health behaviours. Why do young people smoke? And why do so many of them take up sports? Youngsters do things because of what�s in their head: knowledge, feelings, intentions, and perceptions of skills determine whether or not they take up healthy habits. But young people also act in response to their environment. You can�t do the healthy thing, if healthy products or services are not available. And often, we uncounsciously do things because a cue in the environment elicited a particular behaviour.

11. Theory of Planned Behaviour There are plenty of models to describe determinants of health related behaviours, and this one, the theory of planned behaviour, is perhaps the most widely used one. There are plenty of models to describe determinants of health related behaviours, and this one, the theory of planned behaviour, is perhaps the most widely used one.

12. Environmental correlates of behaviour What I want to stress, is that our micro environment has a powerful influence on our health behaviours. Alcohol consumption, for example, is linked to very specific contexts. If we go to the pub, most people will think it�s all right if we order a pint. Having a pint in a conference room is not done, even though you may well prefer having a drink over listening to me going on about health behaviour determinants. What I want to stress, is that our micro environment has a powerful influence on our health behaviours. Alcohol consumption, for example, is linked to very specific contexts. If we go to the pub, most people will think it�s all right if we order a pint. Having a pint in a conference room is not done, even though you may well prefer having a drink over listening to me going on about health behaviour determinants.

13. Select appropriate outcomes Modifiable? No. Genetics. Not by the school. Food safety, nutrient levels, taxes. Yes. Access to healthy food during lunch / safe bicycle lanes / smoking bans Knowledge / attitudes / skills / intentions To get back to our starting point: what are appropriate outcomes to look at when we use schools as health promotion settings? First of all, we can only tackle modifiable outcomes. We can�t mess about with pupils� genetic endowment. And we can�t do squat about many important determinants of health and health behaviour, such as taxes on cigarettes, or additives in food. We can only work effectively if we tackle those factors that WE can change. That is your second take-away message. You can change what is in pupils� heads, to some degree. And you can also make sure that the school environment fosters healthy choices. That is all you can do. Which means of course, that the effects you obtain will largely contain themselves to level 3. It is almost impossible to show that interventions in the school setting have a profound impact on pupils� health status. To get back to our starting point: what are appropriate outcomes to look at when we use schools as health promotion settings? First of all, we can only tackle modifiable outcomes. We can�t mess about with pupils� genetic endowment. And we can�t do squat about many important determinants of health and health behaviour, such as taxes on cigarettes, or additives in food. We can only work effectively if we tackle those factors that WE can change. That is your second take-away message. You can change what is in pupils� heads, to some degree. And you can also make sure that the school environment fosters healthy choices. That is all you can do. Which means of course, that the effects you obtain will largely contain themselves to level 3. It is almost impossible to show that interventions in the school setting have a profound impact on pupils� health status.

14. Make healthy changes Target most important factors Use evidence based methods Frame them in a healthy school policy A balanced set Of complementary interventions So, we know what we want to achieve. Now, how shall we do it? We target the most important factors, and these may differ across schools or even across grades within schools. We use evidende based methods And we frame all those interventions in a healthy school policySo, we know what we want to achieve. Now, how shall we do it? We target the most important factors, and these may differ across schools or even across grades within schools. We use evidende based methods And we frame all those interventions in a healthy school policy

15. Assess �baseline�: which health related behaviours are most prevalent? Studies on school aged children School-specific data: observations or questionnaires Avoid pitfalls Focus on crises (drug dealing) Focus on �troublesome� behaviours (smoking) Forget unobtrusive behaviours (unhealthy diet) Forget what pupils do behind your back (bullying) Target most important factors You know what they say about kids. They don�t eat right. They smoke. They drink alcohol. They don�t buckle up in the car. There are so many behaviours we ought to change for the better. We can�t do all of that. So how do we pick the right one? Well, visit your university library. There are heaps of studies on health related lifestyles of young people. If a representative sample of the population has a unhealthy diet, I�ll bet that pupils in your school are not eating healthy either. Of course, you can probe deeper and look at data from your school. You can observe things, or have pupils fill out questionnaires. It is very important that you take the time to carefully consider what your priorities are. You will avoid the following pitfalls: You will avoid having your interventions dictated by crises at school. If pupils are caught dealing drugs on school premises, schools tend to panic and launch a massive campaign to diminish illicit drug use. In fact, use of legal substances such as alcohol or tobacco may present much more of a problem You �ll avoid an exclusive focus on troublesome behaviours. Don�t tackle smoking at the school gate because it tarnishes your school�s reputation. Maybe your analysis of the situation indicates that you�d be better off promoting physical activity. you will remember to do something about unhealthy habits that are not clearly visible, such as low vegetable consumption or bullyingYou know what they say about kids. They don�t eat right. They smoke. They drink alcohol. They don�t buckle up in the car. There are so many behaviours we ought to change for the better. We can�t do all of that. So how do we pick the right one? Well, visit your university library. There are heaps of studies on health related lifestyles of young people. If a representative sample of the population has a unhealthy diet, I�ll bet that pupils in your school are not eating healthy either. Of course, you can probe deeper and look at data from your school. You can observe things, or have pupils fill out questionnaires. It is very important that you take the time to carefully consider what your priorities are. You will avoid the following pitfalls: You will avoid having your interventions dictated by crises at school. If pupils are caught dealing drugs on school premises, schools tend to panic and launch a massive campaign to diminish illicit drug use. In fact, use of legal substances such as alcohol or tobacco may present much more of a problem You �ll avoid an exclusive focus on troublesome behaviours. Don�t tackle smoking at the school gate because it tarnishes your school�s reputation. Maybe your analysis of the situation indicates that you�d be better off promoting physical activity. you will remember to do something about unhealthy habits that are not clearly visible, such as low vegetable consumption or bullying

16. Target most important factors Assess �base line�: how healthy is the school environment? Rules and regulations Availability Of healthy alternatives (water fountains) Of unhealthy options (soft drink vending machines) Structural facilitators, cues and barriers Trees and shrubs = smoking Trees and shrubs = active play Remember, the environment makes kids choose healthy or less healthy options. So it�s a good thing to chart that micro-environment. What rules do we have at school? If pupils want to adopt a healthy diet, do we support them by providing healthy snacks or do we foil their plans by having a vending machine filled with mars bars? Trees and shrubs provide plenty of hiding space, so pupils can smoke. On the other hand, shrubbery also invites active play in young children. Remember, the environment makes kids choose healthy or less healthy options. So it�s a good thing to chart that micro-environment. What rules do we have at school? If pupils want to adopt a healthy diet, do we support them by providing healthy snacks or do we foil their plans by having a vending machine filled with mars bars? Trees and shrubs provide plenty of hiding space, so pupils can smoke. On the other hand, shrubbery also invites active play in young children.

17. Target most important factors Assess �base line� Which behavioural determinants are most influential? I smoke because I can�t say no? I smoke because my friends do? I smoke because I need the nicotine? Let�s say we agreed upon the behaviour that needs to be changed. Then we should make a second analysis and investigate why pupils behave the way they do. We often think that young people smoke because they can�t say no to drugs. In fact, that is not always true. Friends adopt each other�s habits, likes and dislikes. And pupils who have been smoking for quite a while, may be hooked on nicotine. If you know why pupils smoke, or don�t exercise enough, then you have a solid basis on which to design effective interventions. Let�s say we agreed upon the behaviour that needs to be changed. Then we should make a second analysis and investigate why pupils behave the way they do. We often think that young people smoke because they can�t say no to drugs. In fact, that is not always true. Friends adopt each other�s habits, likes and dislikes. And pupils who have been smoking for quite a while, may be hooked on nicotine. If you know why pupils smoke, or don�t exercise enough, then you have a solid basis on which to design effective interventions.

18. Use evidence based interventions Evidence based� Intervention was proven effective (randomized controlled trial) Experts say the intervention is likely to be effective Let�s move forward to the next step: the design of an intervention. We don�t want to improvise in a happy-go-lucky way. We want some guarantee that what we do will have a good effect. Therefor we use evidence based methods, which means that it has been proven that the method leads to the desired results or that it is likely to do so. We�ll take a look at effective methods later on.Let�s move forward to the next step: the design of an intervention. We don�t want to improvise in a happy-go-lucky way. We want some guarantee that what we do will have a good effect. Therefor we use evidence based methods, which means that it has been proven that the method leads to the desired results or that it is likely to do so. We�ll take a look at effective methods later on.

19. Healhy school policy What is a healthy policy? Comprehensive set of complementary actions/interventions Fosters continuity Sustainable Subscribed by all major stakeholders Last but not least, an effective method will only lead to perceptible changes if we combine it with complementary interventions that are maintained over time, sustainable and subscribed to by all major stakeholders. Last but not least, an effective method will only lead to perceptible changes if we combine it with complementary interventions that are maintained over time, sustainable and subscribed to by all major stakeholders.

20. Healhy school policy Actions On 4 platforms In 3 pillars Or to put it in less expensive phrasing: we want most cells, if not every cell in this table filled in. Or to put it in less expensive phrasing: we want most cells, if not every cell in this table filled in.

21. Healhy food policy Here is an example about a healthy food policy at school. our first pillar, education, is often limited to the platform of the class room. But if a kindergarten teacher motivates pupils to eat the banana mum put in their lunchbox, that too is education. Here is an example about a healthy food policy at school. our first pillar, education, is often limited to the platform of the class room. But if a kindergarten teacher motivates pupils to eat the banana mum put in their lunchbox, that too is education.

22. 3 axes (1) Axis 1: proactive � remedial Remedial = deal with existing problem Prevention = make sure a problem does not occur (primary) does not get worse (secondary) does not lead to negative side effects (tertiary) Proactive = vouchsafe strenghts and protective factors The table on the previous slide should give a cross section of what the school is doing at the moment. If there are blanks, we might want to fill them in. We also want our actions spread nicely along 3 axes or continua. If there is a problem, we want to deal with it. We also want to avoid problems in the future. And we go beyond the problem. Let�s not forget that some things are ok at school. If children do engage in active play, or if teenagers say they feel happy at school, we want them to continue. Therefore we will vouchsafe those determinants that protect children. The table on the previous slide should give a cross section of what the school is doing at the moment. If there are blanks, we might want to fill them in. We also want our actions spread nicely along 3 axes or continua. If there is a problem, we want to deal with it. We also want to avoid problems in the future. And we go beyond the problem. Let�s not forget that some things are ok at school. If children do engage in active play, or if teenagers say they feel happy at school, we want them to continue. Therefore we will vouchsafe those determinants that protect children.

23. From proactive to remedial Remedial Change attitude towards sport from - to + Tackle obesity Preventive Set up watch in toilets (smoking prevention) Zero-tolerance for �teasing� overweight children Proactive Plant trees on school grounds (active play) Teachers welcome parents and toddlers at school gate To give a few examplesTo give a few examples

24. 3 axes (2) Axis 2: person � environment Persons Change what people think / believe / want / feel / can do / intend / plan In individual or group sessions Environment Physical environment / cues / access and availability Socio-cultural environment / financial aspects / rules and regulations There�s a second axis on which we want our actions spread nicely, and that is one we have dealt with before. We want to change what pupils feel and think and we want the environment to encourage them to choose the healthy option.There�s a second axis on which we want our actions spread nicely, and that is one we have dealt with before. We want to change what pupils feel and think and we want the environment to encourage them to choose the healthy option.

25. Actions directed at persons Health education Knowledge dissemination Skills training Attitude change Motivational techniques Express your intentions (�anti-bullying manifesto�) Encourage all pupils in PE class

26. Changes in environments Healthy rules and regulations At home At school Marketing tricks �check this out� sign pointing to healthy sandwich in buffet Healthy facilities Soap and clean towels in toilets!

27. 3 axes (3) Advisory � emancipatory Advisory = expert identifies priorities School staff design health education curriculum Leaflet on �healthy snacks� for parents Emancipatory = health promotor as coach Pupils decide on what to do and how to do it Active participation from parents Finally, we don�t want to be unsufferable know-it-alls. Ok, we are experts at health promotion. So we give lots of advise to pupils, and school staff and parents. What we tend to forget, is that our target group also has great ideas about what needs to be changed and how we can change it. That is amazingly difficult for an expert. Because you might have to go slower. Or your target group sees other priorities than you do. Don�t worry. Follow their advice. It will give you an excellent basis from which to launch other projects. Finally, we don�t want to be unsufferable know-it-alls. Ok, we are experts at health promotion. So we give lots of advise to pupils, and school staff and parents. What we tend to forget, is that our target group also has great ideas about what needs to be changed and how we can change it. That is amazingly difficult for an expert. Because you might have to go slower. Or your target group sees other priorities than you do. Don�t worry. Follow their advice. It will give you an excellent basis from which to launch other projects.

28. We now know what a healthy school policy looks like. So, how are we going to evaluate if we�re doing the right stuff in the right way? That is what we will discuss in the next part of the presentation.We now know what a healthy school policy looks like. So, how are we going to evaluate if we�re doing the right stuff in the right way? That is what we will discuss in the next part of the presentation.

29. What to evaluate? Effects obtained At different levels At appropriate time Process of change Quality of intervention Quality of implementation Feasibility Context of change Matching and complementary interventions Continuity Participation of stakeholders Evaluating our school�s effectivenss at health promotion entails 3 facets We want to know what effects we have obtained We want to know if we obtained those effects in the best way possible And we want to know if we created the best possible context for change Evaluating our school�s effectivenss at health promotion entails 3 facets We want to know what effects we have obtained We want to know if we obtained those effects in the best way possible And we want to know if we created the best possible context for change

30. How to evaluate? Effects obtained Observations By school health councellors e.g. BMI By school staff e.g. physical activity during recess, number of pupils signing up for a �quit smoking� programme By lunch ladies e.g. fruit/yoghurt consumption at lunch time By cleaning personnel e.g. cigarette stubbs in toilets How do you know if you have made a change in pupils� health, health behaviour, or health behaviour determinants? Well, sometimes a simple observation will tell you all you want to know. School doctors or nurses can tell us how body mass indices evolve (but remember, that it is unlikely that we can really affect body mass index) teachers can tell you whether adolescents are more involved in physical education classes, or have more fun doing sports If you want to know if 5 year olds eat their veggies or yoghurt, ask the lunchladies And if you want to know how bad the smoking epidemic is at your school, ask the cleaner, because he is the one who has to pick up the stubbs in the toilet stalls How do you know if you have made a change in pupils� health, health behaviour, or health behaviour determinants? Well, sometimes a simple observation will tell you all you want to know. School doctors or nurses can tell us how body mass indices evolve (but remember, that it is unlikely that we can really affect body mass index) teachers can tell you whether adolescents are more involved in physical education classes, or have more fun doing sports If you want to know if 5 year olds eat their veggies or yoghurt, ask the lunchladies And if you want to know how bad the smoking epidemic is at your school, ask the cleaner, because he is the one who has to pick up the stubbs in the toilet stalls

31. How to evaluate? Effects obtained Self-reports Level = behaviour Life style questionnaires e.g. general DIGG module Self-monitoring Diaries of physical activity Pedometers Level = behavioural determinants Knowledge quiz Questionnaires on other personal and environmental determinants e.g. submodules DIGG Of course, sometimes you will ask your target group specific questions There are several lifestyle questionnaires you can use to chart changes in pupils� health related behaviours Older pupils can use self monitoring devices, such as loggings of physical activies. Or they can carry accelerometers or pedometers, that register objectively how active they are. Of course, you won�t have the money to provide every pupil with a pedometer, but you could use a rota or pick a random sample. You can also use quizzes or questionnaires to investigate what changed inside pupils� heads or in their immediate environmentOf course, sometimes you will ask your target group specific questions There are several lifestyle questionnaires you can use to chart changes in pupils� health related behaviours Older pupils can use self monitoring devices, such as loggings of physical activies. Or they can carry accelerometers or pedometers, that register objectively how active they are. Of course, you won�t have the money to provide every pupil with a pedometer, but you could use a rota or pick a random sample. You can also use quizzes or questionnaires to investigate what changed inside pupils� heads or in their immediate environment

32. How to evaluate? Timing is important! Immediate effects Knowledge That�s it, folks! Changes that take some time Attitude change (balance of pros and cons) Skills (takes practice) I want you to remember this about effect evaluations. Timing is crucial. Another take-away message. You have to be patient if you want people to change their behaviours. Knowledge is the one and only factor that can be changed in an hour�s time. Attitudes are more resistant to change. Let�s face it, we don�t change our mind just like that, so why would we expect young people to change their attitude after a couple of weeks? Skills training also takes time. Remember how long it takes to learn to ride a bike or drive a car? I want you to remember this about effect evaluations. Timing is crucial. Another take-away message. You have to be patient if you want people to change their behaviours. Knowledge is the one and only factor that can be changed in an hour�s time. Attitudes are more resistant to change. Let�s face it, we don�t change our mind just like that, so why would we expect young people to change their attitude after a couple of weeks? Skills training also takes time. Remember how long it takes to learn to ride a bike or drive a car?

33. How to evaluate? Timing is important! Changes that take a long time Behaviour change Only if several determinants change for the better Most people are not willing to change (Transtheoretical Model) Maintenance of change takes � to 1 year Relapse is the rule rather than the exception Change in health status Evaluate effects at appropriate time! Behaviour change takes years. Literally. How come? Well, most people don�t want to change. If I were to say to you that you�d better stop drinking coffee, stop smoking, and take up exercise, I would sound remarkably like your GP, wouldn�t I? And did YOU feel an urgent need to change after he or she gave you sound advise? Secondly, change is a gradual process, and doesn�t happen over night. Health psychologists have a rule of thumb that says real change takes about 6 months to a year. Moreover, relapse is the rule, rather than the exception; people go through several cycles of change and relapse to the old habits before they really make a switch to the new behaviour. What I want to stress is that is complete nonsense to expect sustained change after a couple of weeks. Of course, if you wait longer to measure your effects, pupils have been exposed to external influences, and it will be difficult to tell what proportion of change was instigated by your intervention. It�s a Catch-22. Behaviour change takes years. Literally. How come? Well, most people don�t want to change. If I were to say to you that you�d better stop drinking coffee, stop smoking, and take up exercise, I would sound remarkably like your GP, wouldn�t I? And did YOU feel an urgent need to change after he or she gave you sound advise? Secondly, change is a gradual process, and doesn�t happen over night. Health psychologists have a rule of thumb that says real change takes about 6 months to a year. Moreover, relapse is the rule, rather than the exception; people go through several cycles of change and relapse to the old habits before they really make a switch to the new behaviour. What I want to stress is that is complete nonsense to expect sustained change after a couple of weeks. Of course, if you wait longer to measure your effects, pupils have been exposed to external influences, and it will be difficult to tell what proportion of change was instigated by your intervention. It�s a Catch-22.

34. How to evaluate? Process of change Quality of intervention Quality label? Intervention was tested / fine tuned in similar setting (not often!) Studies indicate: similar interventions were succesful Expert review Intervention is based on sound theory Evaluating the process of change means that we check if we used the best methods of change for the given target group and base line situation. There are few interventions with a bona fide quality label, but I�ll present you with some solid guidelines. Evaluating the process of change means that we check if we used the best methods of change for the given target group and base line situation. There are few interventions with a bona fide quality label, but I�ll present you with some solid guidelines.

35. Quality label interventions Changing people Intentions and implementation plans Attitudes Perception of social norms Skills Changing the environment Barriers and facilitators Cues to action Rules and regulations The school climate

36. Quality label interventions

37. Attitude change (1) Attitudes : 2 components Cognitive component Rational side X is healthy, smart, useful, appropriate, � Affective component Emotional side Feels good, is exciting, relaxing, cool, � Impact affect > cognitive component

38. Attitude change (2) Improve knowledge Factual knowledge Tackle misconceptions Effect? Small effect by itself Medium effect if Information easy to visualize (1 portion vegetables = � grape fruit in size) Tailored Adverse effects Waning interest Resistance

39. Attitude change (3) These are examples of interventions that were used in health promotion campaignsThese are examples of interventions that were used in health promotion campaigns

40. Attitude change (3) Fear appeals Popular in the 80s Effects Short term verbal compliance (�exit-poll�) No benefical effects Adverse effects guaranteed Misdirected fear Avoidance

41. Attitude change (4) Through conditionering Consistent linkages between neutral and +/- stimuli Healthy alternative is fun (Popeye and spinach / the water-balloon condom) tastes good Effect Strong long term effects Aversion therapy? Be careful!

42. Skills (1) Model learning Via media Health education videos Obiquitous media influence (breakfast in the OC) Modelling through peers, parents, teachers� Effect Realistic portrayal of level of difficulty Broadens range of instrumental coping Often mix with evaluative conditioning

43. Skills (2) Practice �Police academy� Let�s make breakfast Condoms in the class room Effect Positive Context specificity! Transfer to real life is not 100% police academy: kids learn to the principle of right of way by riding their bikes under supervision of a police officer adolescents try to unroll a condom over a broomstick police academy: kids learn to the principle of right of way by riding their bikes under supervision of a police officer adolescents try to unroll a condom over a broomstick

44. Social influences (1) Adjust descriptive norms Analyze media messages Correct prevalence estimates of healthy/unhealthy behaviours Effect Positive Impact implicit norms < social support and regulations (= environment)

45. Social influences (2) Social inoculation �Vaccine� for social pressure Recognize implicit / explicit pressure Resist pressure (�just say no�) Effect + or 0 effect Other factors more important? (dare to buy/smoke cigarettes > being able to say no) Context specific!

46. Social influences (3) Social support Buddy-systems Partner up Effect Good Combines memory aids, emotional support, control, reinforcement, public commitment Avoid social pressure and telling people off! Buddy-systeem = emotionele of praktische hulp krijgen bij veranderen Opletten dat het geen machtsspelletje wordt, want dan werkt het niet. Of als sociale steun enkel bestaat uit bekritiseren van wat je fout doet, dan werkt het ook niet. Buddy-systeem = emotionele of praktische hulp krijgen bij veranderen Opletten dat het geen machtsspelletje wordt, want dan werkt het niet. Of als sociale steun enkel bestaat uit bekritiseren van wat je fout doet, dan werkt het ook niet.

47. Intention formation Make intentions explicit A contract with me, myself and I Group manifesto Effect Ink it, don�t think it Implementation intentions The more detail, the better Goals should be ambitious but within reach! Het is goed om je plannen duidelijk en concreet te maken, voor jezelf en voor anderen (zodat zij je kunnen steunen) Opschrijven wat je wil bereiken is heel nuttig. Anders pas je je plannen te snel aan aan het niveau dat je hebt bereikt, en is het niet meer uitdagend. Bijvoorbeeld: je wil geen cola meer drinken bij het eten. niet tevreden zijn als je cola weglaat bij de warme maaltijd, maar nog altijd cola drinkt bij je boterhammen. Het is goed om je plannen duidelijk en concreet te maken, voor jezelf en voor anderen (zodat zij je kunnen steunen) Opschrijven wat je wil bereiken is heel nuttig. Anders pas je je plannen te snel aan aan het niveau dat je hebt bereikt, en is het niet meer uitdagend. Bijvoorbeeld: je wil geen cola meer drinken bij het eten. niet tevreden zijn als je cola weglaat bij de warme maaltijd, maar nog altijd cola drinkt bij je boterhammen.

48. Quality label interventions

49. Structural improvements (1) Availability of alternatives Barriers Remove: Fruit at reduced prices / free of charge Install: speed bumps Facilitators Remove: get rid of ash trays / benches Install: provide drinking fountain / French or Japanese chefs? Effect �Medium� strong

50. Structural improvements (2) Cues to action Stickers or posters promoting stair use Art on stair risers Colourful displays at lunch buffet Effect Cues to action < barriers & facilitators But cheap and easy to install Good complement to other initiatives

51. Rules and regulations Do�s and don�ts At school Candy treats on birthdays? Can the teacher have a pint on a school trip? At home Sleep routine, diet, smoking, medication use Effect Good, if applied consistently! Avoid punishment Work with parents to �synchronize� rules and regulations across settings

52. The school climate Pupils like school ? unhealthy habits ? The school climate as protective factor Genuine interest in health and wellbeing of children and adolescents Good class climate Healthy values and norms (e.g. calling girls �sluts� is NOT �teasing�) Clean and aesthetically pleasing class rooms and play grounds

53. How to evaluate? Process of change Quality of implementation Did we use the right materials? Did we reach the target group? Was the target group consulted? What was their perception of the intervention? Did partners contribute what was agreed upon? Was our communication sufficient? Feasibility How was our timing? Was our budget sufficient? What about the workload?

54. How to evaluate? Context of change Progress made in Filling in the 4 platforms /3 pillars schedule? Spreading interventions across 3 axes? Continuity within curriculum and with extra-curricular activities? Policy evaluation

56. Useful links � in Dutch For Flanders VIG = Vlaams Instituut voor Gezondheidspromotie: www.vig.be www.gezondeschool.be The Netherlands www.gezondeschool.nl www.nigz.nl

57. Useful links � in English www.healthpromotingschools.co.uk European network of health promoting schools www.euro.who.int/ENHPS Australian health promoting schools organization www.ahpsa.org.au WHO = World Health Organizationwww.who.int/school_youth_health/gshi/en