Critically important whole school healthpromotion work has to be sustained:Shifting from program thinking tosystem thinkin...
Take home messageMost effective HP programs seem to be thosethat harness dynamic properties of systemsWe may be able to us...
Eras of health promotion1970s and 80sTesting phase         1990s          Sustainability phase                   Early 200...
Prevention Studies, Implementation Findings     Battish et al (1996)                         33% of schools implemented   ...
Evidence on what gets sustainedProven effectiveConsumer and practitioner involvement$ or in-kind support from outsetStable...
Prevention Studies, Implementation Findings     Battish et al (1996)                         33% of schools implemented   ...
12
Look inside the “black box” of the program    to understand more about it and the    change processes going on in and arou...
A tale of two projects    Hutchinson Smoking Prevention Project    (USA)    Gatehouse Project (Australia)8
5
6
Gatehouse Project 26 Australian metro and rural high schools A collaborative intervention to improve social environment at...
Gatehouse Project – OrganisationalDevelopment over 2 yearsEntrySurvey, interviewsFeedbackPriority settingActionsImplementa...
Towards a more positive social environment(Patton G, Bond L, Butler S, Glover S)Classroom                          Whole s...
The Gatehouse Project: changes in health     risk behaviour in year 8 students after 2     years             120          ...
Key milestones         2001   Whole school mental health promotion                symposium, Calgary   2002 - 2004   CORE ...
Social network analysis is the study of socialstructure.It maps relations among people (or organisations)A person‟s positi...
The basicsNodes, actorsTies - role based (eg brother of, boss of)     -cognitive, affective (eg., likes, knows)     - acti...
School Staff and Teacher NetworkSurvey (complete network n=50)Assessed          - knowing by name                  - regul...
Staff. Advice seeking a year ago
Staff. Advice seeking now
Density of relationships, before and after (%)                          Before    AfterKnowing by name           66       ...
Insight Maybe this is the „real magic „ of the intervention Maybe explains why it`s easy to do things in some places and h...
Students. The talk-to-when-upset network at Time 1One elementary classroom
Students. The talk-to-when-upset network at Time 2,same class
Play at school together, grade 6, baseline assessmentcoded by typical peer rated behaviour
Key milestones in the transfer          2001    Whole school mental health promotion                  symposium, Calgary  ...
A tale of two projects    Hutchinson Smoking Prevention Project    (USA)    Gatehouse Project (Australia)8
A tale of two projects    Goliath versus David?    Individual versus system?    Controlled versus flexible?    Unlucky ver...
More about contextsÉ
Contextual turbulence in a whole-schoolhealth promotion projectover four years                        School School      S...
Thinking of my teachers this term,     I really like……..     All of them       14%     Most of them      42%     Half of t...
Implications of moving from programthinking to system thinking1. Can‟t activate and draw on what each part has   to give i...
DARE Drug Abuse Resistance Education•   33 million children 1983-1997, no evidence of    effectiveness•   Costly. Average ...
Implications of moving from programthinking to system thinking5. Give more power to school to choose but   regulate the qu...
Implications of moving from programthinking to system thinking5. Give more power to school to choose but   regulate the qu...
Incidental references to smoking in Calgary Herald   and Edmonton Journal, over a 3 year period60          May-01   Apr-02...
Implications of moving from programthinking to system thinking5. Give more power to school to choose but   regulate the qu...
Implications of moving from programthinking to system thinking10.Sustain, invest, expand, mainstream11. Prompt others to c...
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
Hawe dh vic november 2011 school hp (pp tminimizer)
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Hawe dh vic november 2011 school hp (pp tminimizer)

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Critically important whole school health promotion work has to be sustained: Shifting from program thinking to system thinking
Penny Hawe
Population Health Intervention Research Centre
University of Calgary , Canada
www.ucalgary.ca/PHIRC phawe@ucalgary.ca

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Hawe dh vic november 2011 school hp (pp tminimizer)

  1. 1. Critically important whole school healthpromotion work has to be sustained:Shifting from program thinking tosystem thinkingPenny HawePopulation Health Intervention Research CentreUniversity of Calgary , Canadawww.ucalgary.ca/PHIRCphawe@ucalgary.ca A CIHR Centre for Research Development in Population Health
  2. 2. Take home messageMost effective HP programs seem to be thosethat harness dynamic properties of systemsWe may be able to use these insights to designand sustain more effective interventionsImplications are wide ranging (but not tooscary!)
  3. 3. Eras of health promotion1970s and 80sTesting phase 1990s Sustainability phase Early 2000s Systems phase
  4. 4. Prevention Studies, Implementation Findings Battish et al (1996) 33% of schools implemented the program properly Rohrbach et al (1993) 79% teachers omitted program components Taggart et al (1990) 45% teachers implement properly Flannery et al(1993) 67% teachers miss key componentsDulak JA, J Prev & Intervention in the Community 1998;17:5-18
  5. 5. Evidence on what gets sustainedProven effectiveConsumer and practitioner involvement$ or in-kind support from outsetStable, mature host organisationCompatible mission between host and programIntegrated, not run as separate unitFinancially viableHigh level champion
  6. 6. Prevention Studies, Implementation Findings Battish et al (1996) 33% of schools implemented the program properly Rohrbach et al (1993) 79% teachers omitted program components Taggart et al (1990) 45% teachers implement properly Flannery et al(1993) 67% teachers miss key componentsDulak JA, J Prev & Intervention in the Community 1998;17:5-18
  7. 7. 12
  8. 8. Look inside the “black box” of the program to understand more about it and the change processes going on in and around it Started to gain more appreciation of the schools, in built capacity of “the agents”,8
  9. 9. A tale of two projects Hutchinson Smoking Prevention Project (USA) Gatehouse Project (Australia)8
  10. 10. 5
  11. 11. 6
  12. 12. Gatehouse Project 26 Australian metro and rural high schools A collaborative intervention to improve social environment at school Randomised controlled trial Centre for Adolescent Health , University of Melbourne
  13. 13. Gatehouse Project – OrganisationalDevelopment over 2 yearsEntrySurvey, interviewsFeedbackPriority settingActionsImplementationEvaluation Action team (staff, students, parents) Part time facilitator Curriculum Professional development
  14. 14. Towards a more positive social environment(Patton G, Bond L, Butler S, Glover S)Classroom Whole schoolSecurity Security• clear and agreed class rules • implementation and monitoring of• no put-downs victimisation prevention strategies• maintaining privacy CommunicationCommunication • moving towards organisational• promoting listening to others change• promote opportunities for one- • peer support program – on-one interaction with teachers coordination and training• physical layout of classroom • student-teacher engagement• small group work outside of class eg mentoringPositive regard through Promote participation participation • organisational change to allow• part of the group and have student representation something to contribute • promotion of extra-curric. activities• promote acknowledgment of • create opportunities for feedback to others contribution and work students (and teachers)
  15. 15. The Gatehouse Project: changes in health risk behaviour in year 8 students after 2 years 120 100 80% of group Comparison schools 60 Intervention 40 20 All analyses 0 adjusted for Smoking Regular Binge Cannabis Weekly previous level of smoking drinking Cannabis substance use in the school
  16. 16. Key milestones 2001 Whole school mental health promotion symposium, Calgary 2002 - 2004 CORE high school pilot
  17. 17. Social network analysis is the study of socialstructure.It maps relations among people (or organisations)A person‟s position in a structure determines theopportunities or constraints that the person willencounter -information, - help -viewpoints -approval/disapproval - affirmation of worth
  18. 18. The basicsNodes, actorsTies - role based (eg brother of, boss of) -cognitive, affective (eg., likes, knows) - actions (eg., talks to, plays with)Density and centrality
  19. 19. School Staff and Teacher NetworkSurvey (complete network n=50)Assessed - knowing by name - regular conversations - knowing more personally - advice seeking - socialisingTwice. At the start, and one year after theintervention.
  20. 20. Staff. Advice seeking a year ago
  21. 21. Staff. Advice seeking now
  22. 22. Density of relationships, before and after (%) Before AfterKnowing by name 66 95Knowing more personally 29 39Regular conversations 26 41Seeking advice 15 21Socialising with 6 8
  23. 23. Insight Maybe this is the „real magic „ of the intervention Maybe explains why it`s easy to do things in some places and harder in others Led to workplace-focused school improvement work in CORE as essential first step
  24. 24. Students. The talk-to-when-upset network at Time 1One elementary classroom
  25. 25. Students. The talk-to-when-upset network at Time 2,same class
  26. 26. Play at school together, grade 6, baseline assessmentcoded by typical peer rated behaviour
  27. 27. Key milestones in the transfer 2001 Whole school mental health promotion symposium, Calgary 2002 - 2004 CORE high school pilot 2004-2008 4 elementary and Stronger one junior high teacher/workplace focus Extended social network analysis into the students 2009/2010 CORE final pilot (elementary) Added a cortisol assessment Launched an RCT in 2010/2011
  28. 28. A tale of two projects Hutchinson Smoking Prevention Project (USA) Gatehouse Project (Australia)8
  29. 29. A tale of two projects Goliath versus David? Individual versus system? Controlled versus flexible? Unlucky versus lucky?8
  30. 30. More about contextsÉ
  31. 31. Contextual turbulence in a whole-schoolhealth promotion projectover four years School School School School 1 2 3 4Change in principal 1 0 6 1Change in vice vacant 2 2 1principalStaff turnover 43% 35% 74% 59%Student turnover 65% 41% 59% 27% Omstead et al. Advances in School Mental Health Promotion 2009
  32. 32. Thinking of my teachers this term, I really like…….. All of them 14% Most of them 42% Half of them 16% One or two 25% None of them 3%13
  33. 33. Implications of moving from programthinking to system thinking1. Can‟t activate and draw on what each part has to give if a system not interconnected in first place – social health groundwork2. Start where they are at (fix lights in the toilets)3. Don‟t just offer your favourite program – help sort, choose, add and take away4. Recognise the function played by “useless” programs
  34. 34. DARE Drug Abuse Resistance Education• 33 million children 1983-1997, no evidence of effectiveness• Costly. Average of $217-$334 per child per year• Renovated at cost of $13.7m, still not known if effective
  35. 35. Implications of moving from programthinking to system thinking5. Give more power to school to choose but regulate the quality of the HP offerings including those in non profit and voluntary sector
  36. 36. Implications of moving from programthinking to system thinking5. Give more power to school to choose but regulate the quality of the HP offerings including those in non profit and voluntary sector6. Measure background contextual change
  37. 37. Incidental references to smoking in Calgary Herald and Edmonton Journal, over a 3 year period60 May-01 Apr-02 Jan-035040302010 0 incidental - as an entertainer/sports incidental - other than entertainment
  38. 38. Implications of moving from programthinking to system thinking5. Give more power to school to choose but regulate the quality of the HP offerings, including those in non profit and voluntary sector6. Measure background contextual change7. Increase feedback about performance8. Reward evaluation regardless of results9. Widen what is measured (including cost)
  39. 39. Implications of moving from programthinking to system thinking10.Sustain, invest, expand, mainstream11. Prompt others to care – public demand and accountability as a new system driver for health promotion ....”My School”

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