Building Competency for Health Promoting Schools Development in Resource-Limited Settings: Case Studies from South Africa

2.1.1 Needs assessment

The needs assessment used a sequential explanatory design with mixed method research, including a survey questionnaire for quantitative data collection among a representative sample of grade 9–11 learners (n=828) from eight randomly selected public schools in the area; semi-structured interviews with four key informants and in-depth interviews with seven student representatives. Ethics approval was granted by the Turfloop Research Ethics Committee and permission to conduct the study in the schools granted by the Department of Basic Education and other stakeholders. Informed consent was obtained in writing from the participants as well as parents of learners under the age of 18 years. Anonymity and confidentiality were guaranteed throughout the study.

The questionnaire included sections related to demographic and socioeconomic indicators, risk behavior, physical school environment and school climate and ethos. The questionnaire had been used in previous research in the area where its internal consistency had been established [15]; translated in the local language (Sepedi); and, administered by a trained researcher. The interview topic guide was grounded in the quantitative results. Instruments were pilot-tested before data collection and analysis was done descriptively for quantitative data and using Tesch’s open coding technique for qualitative data analysis [16].

The most common health risks reported by learners included: (a) Substance use, particularly alcohol, followed by (b) sexual and reproductive health; and (c) bullying. Other substances apart from alcohol, included cigarettes and dagga smoking. Keeping more than one sexual partner was common and teenage pregnancy was frequently observed, even among learners in lower grades such as Grade 9, in line with previous studies [17, 18]. Unsafe sexual behaviour tends to be aggravated in rural and under-equipped schools as in Mankweng and other parts of Limpopo Province [19]. Many schools in rural areas also lack facilities such as dedicated sports grounds, and safety on the way to and from school is a health risk, especially for female learners vulnerable to crime.

Factors related to the school climate revealed the availability of safe clean water and garbage disposal in most schools, sufficient sanitation, discussion of health topics in the curriculum and learner involvement in local events. As regards environmental and physical factors, low cleanliness was reported in all schools, as well as vandalism, which is rampant and associated with gangsterism, school drop-outs, and ex-learners. Research indicate that juridical, economic, drugs and alcohol, and learner-related problems are important causes of vandalism [20]. Other environmental problems included cleanliness of toilets, safety and security, and the wider social environment.

Internal and external factors at school included issues related to management and planning, e.g., presence of a governing body and representative council of learners at each school. Ongoing evaluation of HPS highlighted several benefits that are part of school management objectives, including better learning outcomes, promoting staff health, creating a coordinated approach to social, physical as well as environmental needs. This study reported a need for HPS training of educators, in line with results from a study in the Western Cape [21], to enable learners to accept HPS. This was also linked to delays in the roll-out of the Life Skills program due to limited resources and capacity, especially in rural provinces such as the Eastern Cape and Limpopo.

Existing policies within the school environment provide for a course of action to address the social challenges faced by learners. Examples are the revised Integrated School Health Policy (2012) with a health education component on substance abuse. The policy was developed to support learners to adopt health-promoting behaviors, but very little change has been observed, questioning the actual implementation of programs for optimal health. Educators only received training on programs such as Life Skills and HIV & AIDS Education, which is primarily located in the Life Orientation (LO) learning area/subject [22].

District office staff cannot visit and support schools often and effectively enough to ensure good quality education. Lack of skills, monitoring and accountability lead to poor policy implementation, inferior training of teachers and bureaucrats. Once-off interventions implemented by different service providers, including the Department of Health, Social Development, Education, and non-governmental organizations, is an approach that fails to bring behavior change among learners, and the LO curriculum does not take into account implementation of HPS, which requires skills that the LO educators do not possess [23].

The LO curriculum emphasizes the importance of skills, values and attitudes, and participation in physical activities and community initiatives, which are all elements of HPS [23]. Skills development of educators is therefore crucial to identify needs and implement continuous school-based programs such as the HPS initiative prescribed by WHO [24] to address health risk behavior that derail learners from achieving their educational goals. Selecting a priority issue can be used as a meaningful point of entry to guide HPS program development, using a sequence of well-defined steps outlined in the next section.

2.1.2 HPS training program development

A training program was developed to train educators in HPS in the study setting, based on a needs assessment, and comprising two-sessions that could be offered as a one to five days’ workshop to ensure that relevant learning was addressed depending on the availability of educators. The first session introduced the HPS concept, and the training program goals, aligned to the WHO Information Series on School health, local action: Creating a Health Promoting School [24]. The second session covered the five steps of initiating HPS, using principles of adult learning guided by Knowles’ theory of pedagogy and andragogy [25]. Next, guidelines for implementation of the training program were developed, followed by its implementation and evaluation.

The training program was designed to provide educators with a practical guide to HPS implementation and to achieve HPS accreditation in the Mankweng area using a series of five steps (Box 1).

Training program objectives, learning outcomes and critical cross-field outcomes focused on: introduction of the HPS concept and its benefits to educators; discussion of the association between health and education within school settings and the need for HPS; selecting priority problems as entry points to HPS training; introducing the steps to be followed when implementing HPS; and evaluating the training program. Learning outcomes were based on these objectives and described accordingly.

Although this was not a formal training program with any National Qualifications Framework level, as expected by the South African Qualifications Authority (SAQA) [27], critical cross-field outcomes (CCFOs) were considered important to guide the lifelong HPS related learning of educators. CCFOs are generic outcomes that inform teaching and learning, and they are deemed critical for building capacity for life-long learning. CCFOs related to this HPS training program were integrated in the material and methodology of the facilitator, and emphasized promotion of active, exploratory, and self-directed learning among educators [26].

Educators should, for example, be able to: identify problems; formulate responses that demonstrate responsible decision-making where critical, and creative thinking; consider different ways of collecting and analyzing data, and evaluating information; work effectively in team, organization and the community; apply scientific skills and show accountability for creating a healthy school environment and looking after the health of others; and understand their environment as a set of interrelated systems by recognizing that problem-solving contexts do not exist in isolation [26].

Development of the HPS training program was informed by the WHO Information Series on HPS [24] and guided by Knowles’ theory [25] around adult learning, which is based on the principles outlined below and adapted to the program (Box 2) [26].

2.1.3 HPS training program implementation and evaluation

The training with educators included data collection which reflected the current situation at participating schools. The focus was directed at risks the learners faced. HPS appeared to be a new concept to participants, and both learners and educators confirmed there were no programs and activities at their school focusing on learner health risk behavior, except for the nutrition program and physical activities, which were done occasionally in some schools outside examination time, and where social workers were deployed at school.

Program activities were based on the principles of adult learning outlined above and included assessment of participants’ expectation of the training program as well as alignment with HPS training program content; explanation of the program topics and its relevance to HPS; sharing of experiences; ranking of health risk behaviors in the respective school settings; and a round of discussion to clarify areas of concern. These activities allowed participants to freely express themselves and engage in the HPS training program using Knowles’ principles of adult learning, including building internal motivation, and capitalizing on individual experiences.

Participants rated the training program as good to excellent, indicating that the training program was an eye opener to responsibilities, which they were not aware of [26]. Participants did not know that there were formal initiatives which could assist schools, parents, learners, and educators to address challenges hampering teaching and learning at school and enhance school health [26]. Educators agreed that their expectations had been met and the imparted knowledge would improve their ability to perform their jobs. They indicated that the training was well planned, informative, empowering, technical, and relevant for application in their school contexts.

2.2.1 Introduction

In the Western Cape, an HPS project was conducted driven by the need to reduce the spread of TB and HIV in secondary schools. The project was funded by the Centers for Disease Control and Prevention and conducted over a period of three and a half years in a resource-limited area with high rates of TB and HIV close to the University of the Western Cape (UWC). The project team comprised an educational psychologist; two members from the Faculty of Education; two from Physiotherapy & Occupational Therapy; one from the School of Public Health; and a school doctor employed by the Provincial Department of Health. This diverse range of expertise and experience was an advantage as it drew on different paradigms because of the different backgrounds.

After an initial workshop to introduce the HPS concept and approach, a series of workshops was held in each school at the start of the project with teachers, students, and parents, as well as a workshop with all schools together [28]. The aim of the first workshop was to identify the needs in the school community around health and well-being, while the second workshop focused on TB and HIV [28]. In groups, participants brainstormed what was already in place to address the challenges of TB and HIV. Using the information from the two workshops, each school subsequently drew up its own plan of action, bearing in mind what was realistically achievable.

Although the funding aimed at capacity development for TB and HIV prevention, the project team used this as an entry point for HPS implementation. The focus was on generic capacity building across the schools. Once the participants became familiar with the HPS approach and the social determinants of TB and HIV, they developed their own agendas based on their perceived relevance and priority [28]. The value of these workshops was that teachers, students, and parents (to a lesser extent) worked together towards realizing the goal of HPS project implementation because they were receptive to its benefits.

2.2.2 Project process and approach

The project team subscribed to certain processes and approaches to facilitate HPS implementation. A HPS committee was formed at each school comprising of teachers, students, and parents (to some extent). A member of the UWC team was appointed to each school to guide implementation via monthly meetings with the HPS committee and separate ad hoc meetings with students and teachers. The team was also directly involved in HPS planning in the initial stages but took a more facilitative role later on.

A participatory approach was used based on the Appreciative Inquiry technique, which applies a positive stance and builds on organizational strengths to encourage growth and development [29]. For example, the HPS committees were asked to draw a dream tree depicting their ambition and a mapping exercise to outline the available resources. The teams worked with those who were receptive and eager to be involved and remained flexible in allowing schools to advance at their own pace and focus on their own plans.

A student camp was held each year focusing on leadership and empowerment to build capacity among students to implement HPS and develop as an individual. The value of the camp was that students were encouraged to explore and reflect on their feelings and capabilities independently of teachers or parents—an opportunity they did not often have. The camp was facilitated by members of the UWC team in addition to other organizations with expertise in youth development, communications, team building and TB and HIV.

2.2.3 Role of the external partner

Studies report that schools often lack the skills and competence to implement any health-promoting change, and hence need external catalysts for change [30, 31]. In this project, the UWC team was perceived as crucial for facilitating implementation. Apart from some financial and material support, they provided technical assistance, e.g., through workshops and skills development activities. Some teachers attended a short course at UWC to improve their HPS skills. The team also provided mentorship, guidance, education, and problem solving with the local HPS school committee.

The team was also seen as giving direction while receiving first-hand information of what was happening in the external and internal social context of the school. The nature of the collaboration of the UWC team with the school was in keeping with the settings approach of using a participatory bottom-up approach right from the start of the project, and its role was perceived as resulting in a valuable relationship with the school: “…without your involvement… and input I don’t think this school would have opened many other doors…” (Teacher, AP3).

Relationship building was also a key role of the school facilitator, who confirmed that through constant in-person interaction a good relationship had been established with the HPS group and the school in general. The facilitator claimed that this contact provided an opportunity to feel the rhythm of the school, enabling to fit in with the way the school functioned. The facilitator felt that this was necessary to consolidate HPS and keep it on the school agenda, a finding which is consistent with other studies on the guiding and supporting role of school health advisors [30].

The findings of this study indicate that as initiators of the HPS concept, one of the key roles of the UWC team was to ascertain that the HPS concept was understood as a whole-school approach and implemented in a way that suited the schools. Its role was hence facilitative and enabling rather than effecting HPS implementation, in line with the findings of Boot et al. [30], which showed that practical assistance, building a trusting relationship and showing proof of professional skills and knowledge were important mechanisms for school advisors to facilitate project implementation.

The team acknowledged that the school knew what was best for them and were “experts” in terms of their own contexts. The team saw reciprocal learning as being crucial to a shared understanding of HPS and its requirements, which was especially important in view of applying a settings approach. The team worked with different actors in the school system (principal, teachers, parents, and students) which allowed them to gain a better understanding of the context and degrees of commitment of the actors and to gain their trust, which is a key aspect of collaborative work [32].

In keeping with the settings approach, the team further networked with external organizations and institutions that could provide services and resources that were conducive to HPS implementation. Implementation of the HPS program was however influenced by internal and contextual factors, which compromised how it was able to effectively implement the integration of HPS as a whole-school approach, all of which could have an impact on whether HPS was to be sustainable in this context [28].

2.2.4 Building capacity for HPS implementation

In this project, capacity building of students was key to facilitate participation in HPS project implementation. Capacity building resulted not only in personal benefits but also contributed to a positive implementation climate by creating an empowering environment. Students from the participating schools attended the leadership camps where skills were developed to implement HPS. In two schools, students were able to put these leadership and other skills to use by taking some responsibility and fulfilling certain roles for HPS.

Although it was clear from this project that students across participating schools had gained knowledge and an understanding of health in its holistic sense, and were committed to the implementation of HPS, findings also indicated that student action differed from school to school. The levels of competence and involvement varied and were influenced by school climate and culture, the internal support received from the headmaster and other staff members, peers, the principal, and the external support received from the UWC team and other external agents.

Student empowerment indeed carries an understanding that, while students have a sense of agency, they need support and guidance from their teachers to support the implementation climate. In this study, students worked closely with the teachers they trusted, who respected and accepted them as persons and who listened to their ideas. This demonstrates the powerful role teachers can play in providing opportunities for students to realize their potential, which happens rarely because of the community context and school culture of excluding students from decision-making [33].

It was evident from the study that, where the students had specific, clearly defined roles in the HPS project, they had a sense of purpose and felt valued since they were trying to make a meaningful difference [28]. Being seen as resources or assets rather than cases increases the chance of empowerment among young people as they will be seen as having the skills and knowledge to bring about change for themselves [32]. Where students are perceived as unequal partners, they may feel disempowered and consequently could become disengaged from HPS [34].

The benefits of HPS involvement for teachers were not evident in this study. This could be because teacher involvement carried more responsibilities than for students or other staff. The benefits for teachers hence cannot be perceived to be similar as for students who only seemed to gain from their involvement, while for some teachers it may have added to their workload. It has been recommended that capacity building for teachers should indeed not only aim at implementing HPS, but also at encouraging and gaining support from and working in partnership with, their peers and other actors [35].

Although some efforts were done by school facilitators to facilitate partnerships through mentoring and guiding of students and teachers, other contextual factors negatively influenced the ability to fully implement HPS as a whole- school approach, including a strike by teachers, and work and personal commitments. One attempt at building capacity among staff was when the UWC team shared the results of their HPS school climate survey with individual schools, giving staff an opportunity to engage and assess how they could integrate it into the curriculum and other school functions.

At the workshop, participants seemed to fully engage with the information, and teachers discussed how they could use it across the curriculum. The UWC team made further attempts to build the capacities of the teachers and staff directly involved in HPS, including organizing a camp to develop understanding of the HPS concept and process and facilitating a short course on HPS, which was attended by some teachers [28]. The activities took place during school holidays, which also meant that teachers had to compromise on their free time to be able to attend the training.

The fact they did this willingly reflects their readiness for change and commitment to building HPS capacity. On the other hand, teachers were not given an opportunity to further build their capacity or put into practice their acquired skills as part of the normal school operations. This might have resulted in teachers feeling less valued for their work and hence not taking ownership of the program [28]. If HPS would have been implemented as a whole-school approach, time would have been allocated to build capacity for HPS implementation by leadership and management.

A key finding related to capacity building was the challenge of continuity due to staff turnover. This had repercussions in terms of the quality of implementation and sustainability, especially if the leaving staff member carried a high responsibility for HPS implementation. This again could have been averted if a whole-school approach had been taken. Where responsibilities were shared, the potential for integration in the school life was greater. Therefore, leadership capacity must be built at different levels to complement, and, if required, succeed those in leadership positions.