Much of the original work that fostered research-based practice was done in the field of clinical medicine, in an effort to identify the most effective practices for improving patient outcomes. For example, in 1993, the Cochrane Collaboration was formed in England to review results of randomized clinical trials of the most effective treatments of the day. Over time, Cochrane has collected evidence on best practices for treating such conditions as breast and colorectal cancer, dementia, depression and anxiety, cystic fibrosis and many more (Cochrane Collaboration 2004). The Cochrane’s aim is to prepare and maintain systematic reviews of the effects of health interventions and to make this information available to all practitioners, policy makers and consumers.
In the nineties, the trend for research-based practice has gradually moved from clinical medicine to address health education and public health inter-ventions within specific settings, such as schools and community agencies.
National and international organizations have taken steps to define research-based programs and criteria and processes for experts to review and select them. For example, the Cochrane Collaboration’s Health Promotion and Public Health Field now works with the health promotion and health education communities to identify their needs and develop a relevant, useful evidence base (Doyle et al. 2003).
The terms science-based, research-based and evidence-based are used somewhat interchangeably, but the terms mean different things. Evidence-based tends to be broader in meaning than science-Evidence-based or research-Evidence-based and includes the tacit and practical experience of practitioners and others.
110 The Health Promoting School: International Advances in Theory, Evaluation and Practice
Moreover, all evidence is not equal. As defined by Davies et al. (2000), evidence is generally derived from research, in the form of results of systematic investigations that seek to increase knowledge about an issue or phenomenon.
Two characteristics of evidence are 1) it can be independently observed and verified and 2) there is widespread consensus about its content. Nutbeam (2001) presents a very broad definition, offered by the UK Government Cabinet Office, that ‘the raw ingredient of evidence is information. Good quality policy making depends upon information from a variety of sources—expert statistics, stakeholder consultation, evaluation of previous policies, new research, if appropriate, secondary resources.’
In the United States, the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (HHS), has played a leadership role in defining and identifying what the agency refers to as research or science-based programmes for schools and communities. SAMHSA began this effort with substance abuse, mental health and violence prevention programmes and has now extended its work to a broad range of topics. SAMHSA defines a research-based programme as one that:
… produces consistently positive patterns of results. Research-based programs are theory-based, have been rigorously evaluated with sound methodology and can demonstrate that the effects are clearly linked to the program itself and not to extraneous factors, elements or events.
Targeting specific populations, addressing specific risks, the programme can achieve the same results over and over again, with similar audiences in other similar locations (SAMHSA 2002).
To improve professionals’ use of research-based programmes, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Prevention Programs (NREPP). The programmes in this database have been reviewed and scored by teams of social scientists according to 15 criteria, such as underlying theory, intervention, fidelity in implementing the programme as intended, sampling strategy, cultural and age appropriateness and utility, etc. In defining and selecting research-based programmes, SAMHSA argues for review of both quantitative and qualitative data, the first supplying
‘the raw material for the extensive statistical analyses that lend scientific credence to program results’ and the second, ‘rich, descriptive information needed to explain the effects of program interventions’ (SAMHSA 2002:12).
Another example of a national effort, based on legislative authority, is the U.S. Department of Education’s (USED’s) Safe and Drug-Free Schools Program. In 1998 USED established expert panels to identify exemplary and promising programmes that promote safe, disciplined and drug-free schools (USED 2001).
In a two-stage review process, Panels reviewed programmes on substance abuse and violence prevention, for efficacy, quality, educational significance, and usefulness to others, as outlined in Figure 2, U.S. Department of Education’s Criteria for Selecting Evidence-based Programs for Substance Abuse and Violence Prevention. Of 124 programmes reviewed, 9 were designated
‘exemplary’ and 33 were designated ‘promising.’ USED encourages local schools and communities to use their federal funding to implement them.
An important factor in implementation of these programmes is an interagency task force of three U.S. national government ministries: SAMSHA’s Center for Mental Health Services, USED and the Office of Juvenile Justice and Delinquency Prevention (OJJDP). The task force has provided funding to 180 school districts in the Safe Schools/Healthy Students Initiative to implement six different elements of a comprehensive approach, using a research-based programme for each element. (OJJDP 2004). These agencies require schools that receive federal funding to have the same multi-sectoral task force of education, mental health and law enforcement involved in implementation at the local level. In many of the districts funded early in this effort, the local task forces have become institutionalized and remained functioning to operate programmes several years the federal funding ended (Vince Whitman 2004).
On the global level, the International Union of Health Promotion and Education (IUHPE) collaborated with the World Health Organization and others to launch the Global Programme for Health Promotion Effectiveness (GPHPE).
This programme 1) reviews evidence of effectiveness for political, economic, social and health impact 2) translates evidence into publications, which are accessible to for policymakers, teachers and practitioners; and 3) stimulates debate about the evidence itself. A number of products will be developed from this work (WHO 2004).
WHO’s Global School Health Initiative has published an extensive series of documents in its WHO Information Series on School Health, which synthesizes a worldwide research base on effective strategies for addressing particular health issues in schools (WHO 1996–2004).
112 The Health Promoting School: International Advances in Theory, Evaluation and Practice
Figure 2.U.S. Department of Education’s Criteria for Selecting Evidence-Based Programmes for Substance Abuse and Violence Prevention
Evidence of Efficacy
• Indicates a measurable difference in outcomes based on statistical significance testing or a credible indicator of magnitude of effect
• Uses a design and analysis that adequately control for threats to internal validity, including attrition
• Uses reliable and valid outcome measures
Quality of Programme
• Goals with respect to changing behaviour and/or risk and protective factors are clear and appropriate for the intended population and setting.
• Rationale underlying programme is clearly stated; programme’s content and processes are aligned with its goals.
• Programme’s content takes into account characteristics of the intended population and setting (developmental stage,
motivational status, language, disabilities, culture) and the needs implied by these characteristics.
• Programme implementation process effectively engages the intended population.
Educational Significance
• Programme describes how it is integrated into schools’
educational missions.
Usefulness to Others
• Programme provides necessary information and guidance for replication in other settings.
Adapted from USED (2001: 3-4).
In Europe, the IUHPE Report on Health Promotion Effectiveness for the European Commission contains a chapter dedicated to ‘Effective Health Promotion in Schools’ (IUHPE 2000). St. Leger reviews the properties and evidence of effective approaches, which have been used in Europe over the last decade in a framework of the HPS to achieve maximum success in health and education (St. Leger 2000).
Many approaches to school health programmes worldwide—Health Promoting Schools, Child Friendly Schools, Focusing Resources on Effective School Health (FRESH) (UNESCO and WHO 2001) and Coordinated School Health Programs (Marx et al. 1998)—advocate a combination of policy, curriculum-based instruction, health services and a healthy physical and psychosocial school environment, coordinated and targeted to produce specific health outcomes.
The approach of coordinating a few targeted strategies has its roots in groundbreaking preventive medicine studies of the early 1970s, such as the Stanford Three Community Study, which demonstrated that media, combined with intensive community education, led to 20–40-percent reductions in saturated fat intake and cholesterol in both men and women (Stern et al. 1976).
Similarly, the North Karelia Project in Finland used several strategies for a community-based intervention that successfully reduced smoking and improved dietary habits (Vartiainen et al. 1991). None of these preventive medicine programmes relied on only one strategy. A thematic study conducted as part of the Education for All 2000 Assessment reviewed school health developments during the 1990s and found that combined strategies produced greater effects than individual ones, but that multiple strategies for any one audience must be targeted carefully to a specific outcome (UNESCO and WHO 2001).
Most of the evidence base for school health promotion, however, examines only the effects of single components, such as curriculum, each of which is aimed primarily at a single health behaviour. A few studies have begun to research the impact of several coordinated components of a school health programme. For example, O’Donnell et al. (1998) found that combining class-room health instruction with student involvement in community service reduced student risk behaviours more than curriculum alone did. The Child and Adolescent Trial for Cardiovascular Health found that food service changes, enhanced physical education and classroom curricula achieved fat reductions in school lunches and increased physical activity in the target schools as compared to the control schools (Luepker et al. 1996).
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Figure 3.Web Resources for Research-Based School Health Promotion Initiatives
Agency
The Cochrane Collaboration, Cochrane Health Promotion and Public Health Field http://www.vichealth.vic.gov.au/cochrane/
welcome/index.htm
Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services http://prevention.samhsa.gov/
http://preventionpathways.samhsa.gov/
SAMHSA Model Programs, reviewed by the National Registry of Effective Prevention Programs (NREPP)
Office of Juvenile Justice and Delinquency Prevention (OJJDP)
Blueprints for Violence Prevention http://ojjdp.ncjrs.org/
Blueprints for Violence Prevention http://ojjdp.ncjrs.org/publications/ and alcohol, mental and social health and injury. Offers links to the Cochrane library and other databases of evidence-based medicine
Prevention Pathways provides information on prevention programmes, programme
implementation, funding, evaluation TA, online courses and other
resources
Offers alphabetical listings of SAMHSA’s promising programmes, effective programmes and model programmes; a search tool to find programmes in specific content areas including academic achievement, Lists NREPP’s evaluation criteria and explains the review process of potential effective programmes A report of the Blueprints project, an evaluation of over 600 programmes that identified 11 model programmes and 21 promising programmes that prevent violence and drug use and treat youth with problem behaviours.
Report also includes lessons learned about programme implementation and recommendations for those who design, fund and implement such programmes
A recent large national study of U.S. adolescents found that students feelings of connectedness to their school community and to caring adults there (the psychosocial component of a HPS) were the most important factors in reducing risk behaviours (McNeely et al. 2002).
All these studies illustrate how important it is to find and use the best evidence on various elements (or combinations of elements) that lead to reductions in risk behaviours.
St. Leger (2000) has reviewed the properties and evidence of effective approaches for each element used in the HPS framework, in Europe and throughout the world. But, as St. Leger and Nutbeam (2000: 257) note, ‘A paucity of research has examined the effectiveness of using the Health Promoting School framework to address school health issues.’ Until there are more school-based studies of the effects of combined strategies, the best available strategy seems to be to draw from studies of individual components and combine the components for maximum success.
(All websites accessed 21 January 2005) International Union of Health Promotion and Education (IUHPE)
http://www.iuhpe.org
Global Health Programme for Health Promotion Effectiveness (GPHPE)
World Health Organization, School Health and Youth Health Promotion: Global School Health Initiative
http://www.who.int/school_youth_health/
en/
WHO Resources and tools for advocacy http://www.who.int/school_youth_health/
resources/en/
Describes the GPHPE, the need for evidence of health promotion effectiveness and GPHPE’s key contributions to the field Provides descriptions of IUHPE’s projects, the latest news in the field and links to journals, videos and special reports on the topic of health promotion
Provides an introduction to and background of the Global School Health Initiative, resources and tools for assessment and monitoring effective school health programmes, resources and tools for advocacy (links to WHO School Health publications regarding the physical
116 The Health Promoting School: International Advances in Theory, Evaluation and Practice
The websites of these various national, international and regional efforts define their criteria and their review and selection processes, and provide databases that include descriptions of approved research-based strategies and programmes. See Figure 3, Web Resources for Research-based School Health Promotion Initiatives.
The major challenge for educators is to assess whether programmes that have succeeded in one setting with a particular audience will fit their own particular assets, needs and contextual conditions. The next section discusses the capacities and competencies that ministries and schools need to transfer research to practice most effectively.