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The aim of this systematic review was to summarize systematically the existing evidence for the effects of student participation in designing, planning, implementing and/or evaluating school health promotion measures. The focus was on the effects of participation in school health promotion measures rather than on student involvement at school in general. Participation is a core value for health promotion but empirical evidence of its outcomes is scarce. We searched major bibliographic databases (including ASSIA, ERIC, PsycINFO, Scopus, PubMed and the Social Sciences Citation Index). Two reviewers independently decided about inclusion and exclusion of the identified abstracts (n = 5075) and full text articles. Of the 90 full text articles screened, 26 papers met the inclusion criteria. We identified evidence for positive effects, especially for the students themselves, the school as organization, and interactions and social relations at school. Almost all included studies showed personal effects on students referring to an increased satisfaction, motivation and ownership, an increase in skills, competencies and knowledge, personal development, health-related effects and influence on student perspective. Given that student participation has more been discussed as a value, or ideal of health promotion in schools, these findings documenting its effectiveness are important. However, further research is needed to consider the level or intensity of involvement, different approaches and stages of participation in the health promotion intervention, as well as mediating factors such as gender, socio-cultural background or academic achievement, in a more systematic manner.
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Effects of student participation in school health
promotion: a systematic review
URSULA GRIEBLER1*, DANIELA ROJATZ1, VENKA SIMOVSKA2
and RUDOLF FORSTER1
1
Ludwig Boltzmann Institute Health Promotion Research, Vienna, Austria and
2
Department of Education,
Aarhus University, Copenhagen, Denmark
*Corresponding author. E-mail: ursula.griebler@gmail.com
SUMMARY
The aim of this systematic review was to summarize system-
atically the existing evidence for the effects of student par-
ticipation in designing, planning, implementing and/or
evaluating school health promotion measures. The focus
was on the effects of participation in school health promo-
tion measures rather than on student involvement at school
in general. Participation is a core value for health promo-
tion but empirical evidence of its outcomes is scarce. We
searched major bibliographic databases (including ASSIA,
ERIC, PsycINFO, Scopus, PubMed and the Social Sciences
Citation Index). Two reviewers independently decided
about inclusion and exclusion of the identified abstracts
(n¼5075) and full text articles. Of the 90 full text articles
screened, 26 papers met the inclusion criteria. We identified
evidence for positive effects, especially for the students
themselves, the school as organization, and interactions
and social relations at school. Almost all included studies
showed personal effects on students referring to an in-
creased satisfaction, motivation and ownership, an increase
in skills, competencies and knowledge, personal develop-
ment, health-related effects and influence on student per-
spective. Given that student participation has more been
discussed as a value, or ideal of health promotion in schools,
these findings documenting its effectiveness are important.
However, further research is needed to consider the level or
intensity of involvement, different approaches and stages of
participation in the health promotion intervention, as well
as mediating factors such as gender, socio-cultural back-
ground or academic achievement, in a more systematic
manner.
Key words: student participation; health promotion; effects
INTRODUCTION
Following the adoption of the UN Convention
on the Rights of the Child in 1989 (United
Nations General Assembly, 1989), the issue of
children’s participation has become imperative
in policy, research, education and community de-
velopment initiatives in many countries in
Europe and elsewhere. Further, the preamble of
the Revised European Charter on the Partici-
pation of Young People in Local and Regional
Life (Council of Europe, 2008) emphasizes
active participation of youth as essential for
building a better society. Young people have a
right to both having a say and to appropriate con-
ditions to participate in matters of importance to
them. Despite this commitment to participation,
in practice it often remains pure rhetoric and
levels of participation are rather low.
On a conceptual level, participation is a key
component of health promotion. Since the adop-
tion of the Ottawa Charter (World Health
Organization, 1986) and the developments that
followed, participation has been considered as
an invaluable dimension of any strategy to
achieving health promotion objectives, such as
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empowerment of individuals and communities
and addressing the social determinants of health
in addition to individual lifestyles. Unlike many
other concepts within this area, the issue of par-
ticipation is relatively ‘uncontested’. Although
there is no uniform definition of participation
(Simovska and Jensen, 2009a), there is a wide
consensus that active engagement of the target
group is crucial to the effectiveness of health
promotion strategies. Participation of the target
group in the decisions about design and implemen-
tation of health promotion programmes is thought
to be helpful for the applicability, effectiveness in
terms of improved health and health-related
competencies and engagement and sustainability
of such programmes (Clift and Jensen, 2005;
Smith et al., 2006;Reid et al., 2008;Simovska and
Carlsson, 2012).
One can, however, argue that it is because of
the global consensus about the importance of
participation and its normative framing that the
concept in reality often remains on the rhetorical
level (Contandriopoulos, 2004;Potvin, 2007).
The term participation is so widely used that its
meaning turned out to be rather vague and
unclear (Hart, 1997,2008;Simovska, 2007), re-
ferring to very different meanings ranging from
simply taking part in activities, to being informed
or consulted, to having significant influence over
the decisions. This provides little guidance to
practitioners and leads to a highly heterogeneous
practice of undertakings called ‘participatory’.
As discussed by Brandstetter et al. (Brandstetter
et al., 2012), especially the identification of indi-
cators for evaluation of participation presents
challenges for both researchers and practitioners,
particularly if the evaluation is to be scientifically
sound and at the same time nuanced and mean-
ingful for practice. Although some research and
literature reviews have been done, the evidence
that participation in decision-making about
health promotion initiatives has profound effects
either on the health of the target groups or on
the health-related determinants is limited
(Nordin et al., 2010;de Ro
´iste et al., 2012). To
our knowledge, until now no systematic review
on this specific topic in the school setting has
been carried out.
Aims of the review
The main aim of the review was a systematic
identification of the existing evidence for effects
of student participation in school-based health
promotion. Our objective was to specifically look
into participation of students in designing, plan-
ning, implementing and/or evaluating school-
based health promotion measures. Therefore, in
this study we focussed on student participation in
health promotion initiatives rather than on
student participation in other aspects of the
school life.
METHODS
The current review builds on an earlier review
that focused on the overall effects of student par-
ticipation in school decision-making processes,
conducted by the first author of this paper
(Mager and Nowak, 2012).
Working definitions
Student participation
We defined student participation as practices
that involve collaboration between students and
various groups of actors concerning health-related
issues in order to influence decision-making
regarding designing, planning, implementation or
evaluation of health promotion measures (Potvin,
2007). The review endorses the understanding of
participation that distinguishes between a tokenis-
tic and a genuine participation quality. Genuine
student participation is defined as having influence
over the decisions and activities in the school
health promotion processes, rather than simply as
taking part in them (Simovska, 2007;Hart, 2008).
According to this conceptualization, simple forms
of student participation such as answering ques-
tions and taking part in activities (e.g. sports or
music) are not considered participation. We also
do not confine participation to individual decision-
making (as in curricular choices) but rather see it
as a collaborative process.
Health promotion measures in schools
A health promotion measure in school can be a
project, programme, intervention or any other
school-based initiative with the aim to promote
health, health behaviour, health-related compe-
tencies or other social and material determinants
of health for students or other school-related sta-
keholders. This definition is based on the general
definition of health promotion as the process of
enabling people to increase control over and to
improve their health (World Health Organization,
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1986), adapted to school as a health promoting
setting.
Effects of student participation
The effects of student participation are defined
as outcomes, which can be categorized as posi-
tive, neutral or negative (Mager and Nowak,
2012). They are demonstrated using empirical—
quantitative or qualitative—measures (e.g. ques-
tionnaires, interviews, observations) and could
be clearly determined to result from student par-
ticipation in either designing, planning, imple-
menting or evaluating a health promotion
measure.
Literature search
For identifying research evidence we used a com-
bination of several approaches—searching elec-
tronic databases, hand-searching key journals,
checking reference lists and contacting experts.
We focused on empirical studies addressing
student participation in decision-making in
health promotion initiatives at school, published
in international peer-reviewed journals.
We searched keywords, titles and abstracts in
major bibliographic databases of publications
published between 1992 and September 2010.
We used the following keyword combinations:
(student* OR adolescent* OR child*) AND
(participation OR involvement) AND (school)
AND (‘decision making’ OR democracy OR
governance OR ‘health promotion’ OR ‘health
promoting’). Moreover, we hand searched all
issues (from December 2009 to February 2011)
and supplement issues (from 1992 onwards)
from selected journals and we additionally
checked the reference lists of pertinent articles
and contacted experts to provide relevant unpub-
lished studies. Further information on the
detailed search strategy is available in Griebler
et al. (Griebler et al., 2012).
Study selection criteria and procedures
During the study selection process, two research-
ers independently reviewed the abstracts and
relevant full-text articles. Studies were excluded
if both reviewers agreed that they did not meet
the eligibility criteria. Disagreements were either
resolved by a more profound discussion or—if a
consensus could not be reached by considering
the opinion of a third researcher. Books were
excluded due to limitations concerning time,
human and financial resources. Abstract and full-
text review forms were developed and piloted on
a sample of abstracts and full-text articles.
Table 1shows the inclusion and corresponding
exclusion criteria against all abstracts and full-
text articles were screened.
Data extraction and study quality appraisal
For data abstraction a structured form was used.
One reviewer abstracted data from each study.
Then the second reviewer read each abstracted
article and checked the accuracy and complete-
ness of the abstracted data. Disagreements were
resolved via discussion and consensus. We
abstracted data concerning the research question,
the conceptual foundations of the study, the
setting, the student participation processes and
structures, sampling, the data collection process,
the measures of student participation used, the
measures of effects/outcomes of student partici-
pation used, the participants involved, the data
analysis process and results indicating the effects
of student participation. The data extraction
forms were piloted by using a sample of five
studies to ensure consistency and accuracy.
We included studies using quantitative and/or
qualitative methods. For rating the quality of
studies we used checklists for both qualitative
and quantitative studies, developed earlier by
the first author of this paper. Details about the
checklists can be found in Mager and Nowak
(Mager and Nowak, 2012). The following criteria
were the basis for our quality rating: a clear
research question; an appropriate empirical re-
search approach; a clear description of appropri-
ate sampling, data collection and data analysis
procedures; a clear description of the study
context; the findings; the value of the research;
ethical issues and reflexivity (consideration of
potential researcher bias).
Data analyses
To gain a conceptual map describing types of
student participation and different effects of
student participation, we conducted an integra-
tive synthesis using the qualitative text interpret-
ation process presented by Mayring (Mayring,
2000). With this method categories emerge in-
ductively from the data in an iterative process.
As a first step, the relevant text passages from
the original articles on the data extraction sheets
(concerning types of student participation as well
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as effects of student participation) were read and
paraphrased. Thereafter, individual codes were
assigned and then sorted into tentative categor-
ies. By reading and rereading the paraphrases
and codes both categories and codes were
revised and then the categories were reduced
into main categories. To ensure that the categor-
ies fit the original text passages they were cross-
checked by the research team. For helping the
data analysis process we used the qualitative data
analysis software ATLAS.ti (version 6.2.24).
RESULTS
Search results
Altogether 5075 abstracts or titles (if abstracts
were not available) were screened. Of those,
4985 did not meet our eligibility criteria and
were excluded and full texts of 90 abstracts were
retrieved and further assessed. After this step, 64
publications were excluded and 26 publications
were included in the qualitative data analysis
(see Figure 1).
The 26 articles included for data synthesis
discuss 24 studies/projects. Details and character-
istics of these studies are shown in the online
Supplementary data, Appendix 1. According to
the description of student participation in the
original articles we separated the studies roughly
in three types. Firstly, studies with experimental
design including a comparison group (n¼5)
(Wilhelmsen et al.,1994;Mellanby et al., 2001;
Birnbaum et al., 2002;Hamdan et al., 2005;
Carruth et al., 2010). We analysed these studies
separately and they are not part of this synthesis
of effects of student participation because they
had too diverse foci to be analysed together
(general information about these studies can be
found in the online Supplementary data,
Appendix 1).
Secondly, participation of students in different
phases of the intervention (n¼11), and thirdly,
Table 1: Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
Type of study/
publication
All types of empirical studies or reports describing
empirical research about student participation in
decision-making about health promotion
measures at school were included
Publications describing anecdotal experience/not
empirical studies
Books and other grey literature were excluded
except if suggested by experts
Language All reports published in English, German and
Danish were considered
Participants Children and adolescents, in any country, aged
519, who attended primary or secondary school,
private or public schools
Publications describing participation of other
populations (university or college students,
kindergarten children, teachers, parents,
community etc.)
Setting All papers that describe health promotion measures
in the setting school were considered
Publications describing student participation in
another setting than school (e.g. community
health promotion)
Intervention All reports describing student participation in
designing, planning, implementing and/or
evaluating school health promotion were
considered
Publications not describing student participation
according to our definition, i.e. students taking
part in health promotion, but not involved in
planning, designing, implementing and/or
evaluating the health promotion measure
Articles describing participation rates or
interventions to increase participation rates in
health promotion programmes, without
involvement of students in the planning or
organizing phase of the project
Publications describing individual decision-making
of students (e.g. choosing sports lessons, etc.).
Outcome Effects of student participation in designing,
planning, implementing and/or evaluating school
health promotion measures on the participating
students, on other students, on the health
promotion measure or on the school were
considered
Publications without scientific quantitative or
qualitative measure of any effects of student
participation
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studies with a specific study approach (n¼8).
In only one study students participated in
decision-making in all phases of the project from
topic selection to evaluation (Valaitis and
O’Mara, 2005), in five studies students partici-
pated in selection of the topic, planning and im-
plementation (Carroll et al., 1999;Mandel and
Qazilbash, 2005;Gillander Gadin et al., 2009;
Bonell et al., 2010a,b;Rowe et al., 2010), in two
studies in planning, implementation and evalu-
ation of the project (Baskin et al., 2009;Hong
et al., 2010) and in three studies students were
part of the process of planning and implementa-
tion of the health promotion project (Brooks and
Magnusson, 2006;Salmon et al., 2005;Lakin and
Littledyke, 2008). Studies with a specific partici-
patory approach included four studies using a
peer approach (Naylor and Cowie, 1999;Strange
et al., 2002;Streng, 2007;Goenka et al., 2010),
one project using participatory action research
(Lind, 2007) and three studies using the IVAC
(investigation-vision-action-change) approach
(Simovska, 2007,2008;Simovska and Jensen,
2008,Simovska and Jensen, 2009b). We analysed
Fig. 1: Study flow diagram for the study selection process.
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the effects of student participation in these 19
studies together, because there were too few
studies to undertake meaningful comparisons.
Two articles by Bonell et al. (Bonell et al.,
2010a,b) and two articles by Simovska (Simovska,
2007;Simovska and Jensen, 2008) were jointly
analysed, because they each investigated the same
study.
Almost all 19 studies used qualitative data gen-
eration methods or mixed methods; only one
study included in our analysis was a quantitative
study (Naylor and Cowie, 1999).
Almost all publications were rated as having
either good (n¼13) or fair quality (n¼12); only
one publication was rated as having poor, but
sufficient quality to be included.
Effects of student participation
Table 2outlines the effects of student participation
based on a total of 19 studies, of which 11 reported
student participation in different phases of the
intervention and 8 studies documented effects in
relation to specific participatory approaches.
The table presents the following seven meta-
categories; six refer to positive effects of student
participation and one summarizes all negative
effects (in descending order according to their
occurrence in the included articles):
(1) Personal effects on students
(2) Effects on the school as an organization
(3) Effects on interaction and relations
(4) Effects on other stakeholders
(5) Negative effects
(6) Effects on the programme/project
(7) Effects on the local community
Within each meta-category, the effects are further
specified in several categories. The numbers in
brackets in Table 2refer to the number of studies
that documented one or more effects in the par-
ticular meta-category and category, as a relative
indicator of the ‘strength’ of the evidence within
the boundaries of this review, which uses an inte-
grated qualitative synthesis approach.
The comprehensive results of the synthesis of
effects of student participation in school health
promotion are presented in the online Supple-
mentary data, Appendix 2.
Personal effects on students
As shown in Table 2, the review shows the most
evidence for personal effects on students. Within
Table 2: Effects of student participation in health promotion measures at school
Personal effects on students
(18)
Effects on school as an
organization (11)
Effects on interactions
and relations (9)
Effects on other
stakeholders (6)
Negative
effects (6)
Effects on programme/
project (4)
Effects on local
community (1)
Satisfaction, motivation,
ownership (15)
Cultural shift (7) Peer relationships (6) Satisfaction with the
process (2)
* Better inclusiveness of the
programme (2)
*
Skills, competencies,
knowledge (12)
School infrastructure (4) Student– adult
relationships (4)
Work relief for teachers (2) Orientation towards local
needs (2)
Personal development (11) School rules and policies (3) Recognition and
acknowledgement
(2)
Dissemination of
information (2)
Health-related effects (10) Curriculum changes (1) Peer-cooperation (2) Parents behaviour and
commitment (1)
Perspectives (9) School engagement (2)
Usefulness for life in general
(1)
School climate (2)
Identification of service gap
(1)
Acceptance/compliance with
the rules (1)
Organizing events (1)
*No subcategories within this meta-category.
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this meta-category we identified six categories
of effects that included further subcategories
(for details see online Supplementary data,
Appendix 2).
The category satisfaction, motivation and own-
ership refers to affective effects of participation.
These include students’ positive, motivating feel-
ings concerning the participatory processes and a
sense of ownership related to their own product
and/or work. Studies also reported positive stu-
dents’ experience with participation and increased
learning engagement.
The category skills, competencies and/or
knowledge includes cognitive effects reported in
the studies. These refer to increased knowledge
and health-related competencies of students, as
well as an array of specific skills that are benefi-
cial for health promotion but also in more
general terms (e.g. communication skills, organ-
izational skills, collaboration skills, problem-
solving and decision-making skills).
The category personal development includes
effects related to an individual self-perception,
for instance increased self-confidence, self-
esteem and self-efficacy. Similarities and differ-
ences between these concepts are not discussed
in the studies in question, thus the assumption is
that there may be overlap and, arguably, that they
are closely linked with the previous category, par-
ticularly the dimension of competencies.
Health-related effects are reported in more
than half of the studies. As shown in Table 2,
with respect to this category, improved health be-
haviour and increased health literacy were
reported most often. Health literacy can also be
seen as closely linked to the category of knowl-
edge and competencies.
Positive influence on students’ perspectives is a
category that includes students’ attitudes and
problem solving orientation—for example, shift-
ing the focus towards personal and social
resources and potentials rather than deficits and
difficulties when it comes to health promotion.
Students also gained new insights, especially rec-
ognizing participation and collaboration as an
important value.
Effects on life in general, e.g. usefulness for
students’ future career, are mentioned only in
one study.
Effects on school as an organization
The review shows rather strong evidence (in
terms of frequency of the studies that reported it)
for the effects of student participation on the
school as an organization. The school culture was
reported changed in several studies. The change
included a more conducive social environment
towards participatory work. This, for example
manifested in taking students seriously, listening
to them and acting upon their inputs. Moreover,
structural changes in the organization of the
school were also documented, including improve-
ments in the existing school infrastructure or
establishing new infrastructure, changes in school
rules or policies, changes to the curriculum or new
class contents.
Connected to these effects on school as an or-
ganization and in some ways overlapping with or
complementing them are the other documented
effects presented in the table, such as an improved
school engagement, better school climate, identi-
fication of service gaps with a view to improving
it, and better acceptance and compliance with
new rules.
Effects on interaction and relations
The studies that reported effects of student par-
ticipation on interactions and relations at school
referred to improved interactions among peers
but also improvements of student – adult relation-
ships. Other varieties of these effects were also
documented, for example increased sense of
acknowledgement and recognition by peers and
improved peer cooperation. This meta-category
can be seen together with the previous one
(effects on school as an organization) and could
be considered as a part of the improved school
culture.
Effects on other stakeholders
Participation of students in health promotion
measures in school has shown to have effects on
stakeholders beside students, mainly teachers
and parents. Although a smaller number of
studies demonstrated these effects we find them
valuable. The effects that were documented
within this category include general positive feel-
ings and attitudes towards participatory health
promotion work by teachers and/or parents,
relief of the workload of the teachers through
support by the participating students and general
benefits by dissemination of information. One
study documented effects on the behaviour and
commitment of the parents as a result of the par-
ticipatory health promotion work in school.
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Negative effects
As shown in Table 2, several studies (6 studies
presented in 7 publications) documented nega-
tive effects of student involvement in school-
based health promotion. These effects can be on
an individual student level or on a programme
level. On an individual level the negative effects
referred to students feeling ignored or not taken
seriously, and students experiencing participa-
tion to be too challenging, that is, interfering
with their school work. In terms of the pro-
gramme level, the negative effects referred to a
too small number of programme users and, in
some cases, absence of dissemination.
Effects on the programme
Effects on the programme were documented in
only four studies. These included an increased
orientation towards local needs and priorities
and a better inclusiveness of the programme/
project.
Effects on local community
Only one study documented positive changes in
the local community in terms of creating new
and/or improving the existing possibilities for
physical activity as a result of participatory
health promotion in school.
In summary, the review demonstrates that par-
ticipation of students in health promotion in
schools has relatively strong effects on students.
It positively influences their motivation and own-
ership, as well as their knowledge, skills, compe-
tence and confidence to address heath issues. It
also changes their perspectives concerning
health and modifies their health-related behav-
iour. The benefits of participation in terms of life
in general are not conclusively confirmed.
Additionally, positive effects have been shown
on the school as an organization, and on social
interactions at school. Some negative effects
were documented as well, mainly concerning the
feelings of disillusionment or pressure. Limited
positive effects on the programme were docu-
mented in the studies and almost no effects on
the local community surrounding the school.
DISCUSSION
This review maps the diverse effects of student
participation in designing, planning, implement-
ing and/or evaluating school health promotion
measures documented in the literature. We iden-
tified evidence for positive effects, especially for
the students themselves, for the school as organ-
ization and students’ interactions and social rela-
tions at school. Effects that were shown less
frequently were effects on other stakeholders
besides students and negative effects. The least
frequently documented effects were the influ-
ences on the intervention programme and on
local community surrounding the school.
Almost all included studies showed personal
effects on students referring to an increased satis-
faction, motivation and ownership, an increase in
skills, competencies and knowledge, personal de-
velopment, health-related effects and influence
on student perspectives towards health. All the
personal effects on students taken together con-
stitute aspects of ‘action competence’. In the
health promotion and health education literature
action competence is defined as an individual’s
capacity to bring about health-promoting
changes in one’s life, and/or in the health-related
determinants in the everyday life (Jensen, 1997;
Carlsson and Simovska, 2012). The concept has
been developed within the settings approach to
health promotion (Dooris, 2009), particularly
within schools as health-promoting settings
(Nutbeam, 1998;Buijs, 2009). An important di-
mension of action competence is the nature of
the action taken, with a main criterion being that
it should be a result of a conscious decision of the
individual initiating the changes and that it
should be focused on the root causes of the
health problem at hand. This implies a system
rather than an individual approach. In this way,
the concepts of participation and action compe-
tence connect school-based health promotion
with the core task of the schools—learning and
competence development without losing the
focus on health determinants and empowerment.
Action competence need not necessarily be
restricted to health. Regarded in a more generic
manner, it represents the general competence to
initiate changes at school and elsewhere. It can
be considered as an ability of students to actively
participate in democratic processes in the society
and influence matters of their concern (Simovska,
2008,2012). In this way, participation of students
in the process of health promotion at school can
have a profound impact beyond health, contrib-
uting to competences for participation in general
and thus to enforcing the rights of children in a
broader sense. This is consistent with the Article
12 in the UN Convention of the Right of the
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Child stating that ‘States Parties shall assure to
the child who is capable of forming his or her
own views the right to express those views freely
in all matters affecting the child, the views of the
child being given due weight in accordance with
the age and maturity of the child’ (United
Nations General Assembly, 1989).
The differentiations, however, between the
generic action competence and health-related
action competence need to be further explored.
We also found evidence for student participa-
tion improving peer- and student– adult relation-
ships. However, not only the interactions and
relations at school seem to improve, also effects
on the school as an organization were demon-
strated on a structural level (class content, school
policy/rules and infrastructure) as well as on a
cultural level. The latter is coherent with the
effects shown on interactions and relations,
which could be considered as improvement of
the school’s social environment. Therefore, par-
ticipation of students has a potential to contrib-
ute to better interactions and relations at school
but also to a more comprehensive change of the
school culture. Most effects on the organizational
level referred to a participatory culture, indicat-
ing a more sustainable cultural shift.
The school ethos and the atmosphere at school
are considered to be among the central constitu-
ents of the Health Promoting School approach
(Denman et al., 2002;Clift and Jensen, 2005;
Buijs, 2009). Also the development of good rela-
tionships within the school and the promotion of
self-esteem among pupils are emphasized by
guidelines on health-promoting schools (Parsons
et al., 1996). In this sense, we could argue that
participatory health promotion interventions are
conducive to the development of the school as a
health-promoting setting in general, beyond the
specific health topic taken in individual interven-
tions (Dooris, 2009). Thus, the positive effects
shown by this review are corroborating existing
expectations of student participation.
The results of the current review support and
complement the findings of the systematic review
on the general effectiveness of health promotion
in schools conducted by Stewart-Brown (Stewart-
Brown, 2006). Stewart-Brown reports that pro-
grammes are more likely to be effective if informed
by approaches including involvement of the whole
school, changes to the school psychosocial environ-
ment, personal skill development, involvement of
parents and the wider community, and implemen-
tation over a long period of time. All these factors
are also emphasized in the general settings ap-
proach to health promotion (Dooris, 2009).
Similarly, a more recent although smaller scale
review of literature (Nordin et al., 2010) identi-
fied the following outcomes of the participatory
health-promotion programmes: increased motiv-
ation and self-confidence among pupils, increased
knowledge and awareness concerning health
issues and a connection between participatory
health-promotion interventions and healthy life-
styles in relation to smoking, alcohol consump-
tion, diet and physical activity.
Evidently, our review supports these findings
and brings more nuances to the evidence on the
types of effects of the involvement of the stu-
dents in school health promotion.
Beside the promising positive effects, we also
found a few studies showing negative effects, re-
ferring to negative feelings (e.g. not taken ser-
iously) or unmet expectations (e.g. symbolic
rather than real influence). This is suggestive of
the importance to work seriously with high
expectations of students generated by participa-
tory approaches. On the other hand, it was also
reported that students sometimes felt over-
whelmed with the responsibility of participation,
which indicates the need for an appropriate
balance between student support, guidance, au-
tonomy and actual influence—a finding that
seems to hold also for other fields where partici-
patory approaches are promoted (Litva et al.,
2002). The literature on action competence
(Jensen, 2000;Carlsson and Simovska, 2012)
points to the need to further explore the negative
effects of student participation, and the potential
of utilizing these in the pedagogical work with
students, as possibility for learning through
facing and overcoming ‘real-life’ barriers.
Comparing our results with the ones shown in
another recent systematic review on evidence
about student participation in school decision-
making in general, the latter showed basically no
evidence of effects on health, but rather on
school ethos, self-esteem, democratic and life
skills and studentadult relationships (Griebler
and Nowak, 2012;Mager and Nowak, 2012). This
might indicate that the research on health pro-
motion and the discourse on school democracy
are not carried in a synergistic way, and that
these two discourses are parallel, although they
have many aspects in common. This points to the
need to reconnect these two discourses and to
utilize the synergies between them, in terms of
both health and educational outcomes.
Effects of student participation in school health promotion Page 9 of 12
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All in all, it is clear from the literature included
in this review that student participation in
decision-making about health promotion inter-
ventions in schools has a lot to offer in terms of
positive outcomes for students and for schools.
Strengths/limitations
To our knowledge, our review is the first system-
atic review on the evidence of effects of student
participation in designing, planning, implement-
ing and/or evaluating school health promotion
measures. Working with a small, heterogeneous
sample of studies meeting our criteria limits both
meaningful comparison and answering questions
going beyond descriptive and narrative synthesis.
Because of the small number of included studies,
the choice of the narrative, qualitative synthesis
approach and the abundance of effects we could
not elaborate on the strength and quality of
effects more than to point out the effects that
were shown most frequently. Furthermore, it was
not clear from the evidence whether the effects
apply to the majority of the students, or only to
the students participating in the intervention. In
addition, there is no documentation on the sus-
tainability of the effects. This points to the need
for further research, including follow up and
in-depth longitudinal studies. The dominance of
the effects on personal (student) and school (or-
ganizational) level could be a bias of the out-
comes the studies focused on. In general,
publication bias is a well-known problem in all
fields of research—studies with positive results
are more likely to be published than those with
negative or insignificant results (Dickersin,
1990). Furthermore, the included studies and the
approach of summarizing the reported effects
preclude making statements of any missing
effects that may be expected.
Although we made an effort to include grey
literature sources by hand searching journals,
checking reference lists and contacting experts,
we may have missed important work that was
published only in books. The inclusion of studies
published in English, German and Danish may
have excluded important work done in other
languages.
Acknowledging the limitations, we believe
that the evidence on the positive as well as nega-
tive effects identified with this review may help
getting a more in-depth, precise and nuanced
understanding of student participation which can
inspire more comparable studies on this issue.
CONCLUSIONS AND IMPLICATIONS
The review demonstrates positive effects of
student participation in health promotion mea-
sures on their outcomes. The evidence is most
conclusive concerning:
(i) personal effects on students (increased own-
ership, motivation, positive attitudes, skills,
competencies and knowledge, personal de-
velopment, health-related effects and influ-
ence on student perspective)
(ii) effects on school as an organization (school
culture and social climate, rules and policies
and physical infrastructure)
(iii) improved interactions and social relation-
ships in school (among peers and between
students and adults)
These findings support the arguments for inte-
grating participation in health promotion inter-
ventions in schools as one of the important
dimensions of the setting approach to health pro-
motion. Participation is important not only as a
value or norm of health promotion, but also
because it contributes substantially to its effect-
iveness. Within the school context, the effective-
ness of health promotion interventions concerns
both health and education outcomes, and
genuine student participation seems to contrib-
ute to both.
With respect to the scientific discourse on the
effects of participation, there is a need for more
comparable research on this issue and a need of
connecting the various discourses that deal with
student participation essentially. As already high-
lighted, there are a number of benefits when the
discourses on health promotion and on school
democracy were towork more synergistically.
Some questions remain unanswered, such as
why some studies show more positive effects
than others, and why some show negative effects
whereas others do not. Further research could do
well to consider the level or intensity of involve-
ment, different participatory approaches, partici-
pation in different stages of the health promotion
intervention as well as mediating effects like
gender, socio-cultural background or academic
achievement, in a more systematic manner. An
obvious line for further research would be the
development of indicators of participation and
strategies for their measurement.
With respect to the implementation of student
participation, giving teachers a rationale for why
they shall support and foster student participation
Page 10 of 12 U. Griebler et al.
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could support taking action not only for students
but also with them. As participation can have
many faces and we did not find the one most
promising mode of participation, we cannot
suggest the one ideal approach. Depending on the
topic in question (e.g. healthy eating or sexual
education) one approach might be more promis-
ing than another. But with respect to participation
as challenge for both teachers and students,
ongoing information, support and professional de-
velopment could facilitate the cultural, organiza-
tional and attitudinal shift necessary for successful
implementation of student participation and en-
suring its promising effects.
Given that student participation has more
been discussed as a value, or ideal of health pro-
motion in schools, and the evidence on the actual
effects of participation is limited, the findings of
this review are important, especially if student
participation should be taken seriously and uti-
lized as more than mere rhetoric.
SUPPLEMENTARY DATA
Supplementary data are available at HEAPRO
online.
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... However, the implementation of the approach over the past 16 years has been inconsistent across school communities, including lack of rigorous evaluation and youth engagement opportunities (McIsaac (Langille) et al., 2016;McIsaac et al., 2017). This is concerning as the need to collaborate with community partners to develop and enhance healthy school initiatives is widely recognized as valuable (Griebler et al., 2017), yet research related to the benefits of youth engagement in school health promotion is still limited (Beck and Reilly, 2017;Griebler et al., 2017;Sprague Martinez et al., 2020). ...
... However, the implementation of the approach over the past 16 years has been inconsistent across school communities, including lack of rigorous evaluation and youth engagement opportunities (McIsaac (Langille) et al., 2016;McIsaac et al., 2017). This is concerning as the need to collaborate with community partners to develop and enhance healthy school initiatives is widely recognized as valuable (Griebler et al., 2017), yet research related to the benefits of youth engagement in school health promotion is still limited (Beck and Reilly, 2017;Griebler et al., 2017;Sprague Martinez et al., 2020). ...
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The chapter is about benefits of breastfeeding for infant and maternal health.
... Norström et al. defined co-production as "Iterative and collaborative processes involving diverse types of expertise, knowledge and actors to produce context-specific knowledge and pathways towards a sustainable future" (18). The issue of the participation of young people has also gained much recognition in policy, research, education and community development initiatives, and recently in driving forward the climate change agenda globally (19,20). Young people can better identify the problem to be tackled because they understand the needs, experiences and capabilities of young people in ways that adults cannot. ...
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Background Childhood obesity is a serious issue in the Kingdom of Saudi Arabia, but there is no known community intervention. The aim of the study was to use a participatory approach to obtain the perspectives of students, school staff and Ministry of Education (MoE) representatives and parents on important and feasible intervention opportunities for school-based obesity prevention for adolescent girls. Method The study was conducted in two intermediate schools for girls (13–15 years old) in Jeddah that were purposefully identified with the support of the MoE. Group concept mapping, a mixed method approach, was conducted with 19 adults which included staff from the MoE and schools, school canteen suppliers and mothers. Adults generated statements in response to two prompts (P); P1 “ The factors influencing adolescent obesity in Saudi are...” and P2 “ The content of school-based programmes should focus on....” Photovoice-enhanced concept mapping was used with students ( n = 15 students) to capture adolescent perspectives on what influences their dietary and physical activity habits. Students generated statements' using their own photographs. Stakeholders, both adult and students, sorted the statements into themes and rated each statement for relative importance and feasibility. Multidimensional scaling and hierarchical cluster analyses were used to produce concept maps with the input from students and adults. Result Adults generated 35 statements in response to P1 and identified five themes that influenced adolescent obesity including “Home Environment,” “Lifestyle,” “School Environment,” “Community,” “Biology.” They generated 42 statements in relation to P2 and identified four themes including “Ministry of Education Support,” “School Environment,” “Public health programmes” and “Wider environmental influences.” Students generated 42 statements from 39 pictures. They identified five themes that influenced their dietary and physical activity habits—“Role of Government,” “School Environment,” “Home Environment,” “Retail Environment” and “Cultural Practices.” Both groups identified several common important and feasible actions with a strong emphasis on improving the school environment, in particular food provision, with MoE support. Exemplar corresponding statements from adults were “ Offer healthy foods in the canteen,” “Remove chocolates and sweets” and “ Educate children about healthy foods” and from students were “ Offer fruit and vegetables in the canteen,” “Remove chocolates from the canteen,” “Healthy meals should not expensive.” Lack of correspondence related to students' emphasis on access to both healthy foods and physical activity in schools and the wider environment (e.g. retail environments), while adults emphasized school-based education and food provision. After further consultations, both stakeholder groups agreed on improving access to healthy foods in the canteen. Conclusions Students and school and MoE staff jointly agreed that a canteen-based intervention was important and feasible to improve dietary habits and thus help to prevent obesity among adolescent girls. This was the first time a participatory approach was used with students for intervention development in Saudi Arabia. A co-development approach may have value to improve their school food environments.
... Schließlich ergab sich mit Blick auf grundlegende Prinzipien der Gesundheitsfördernden Schule eine geringe Umsetzung für die Kooperation mit kommunalen Akteuren sowie eine geringe Beteiligung von Schüler*innen an der Planung von Maßnahmen der Gesundheitsförderung und Prävention. Vorliegende Übersichtsarbeiten weisen darauf hin, dass Partizipation im Sinne einer aktiven Mitbestimmung und -gestaltung mit positiven Interventionseffekten, u. a. auf individueller und organisationaler Ebene, verbunden ist [32,33]. Ob das Ausmaß an Partizipation in der schulischen Gesundheitsförderung infolge der COVID-19-Pandemie (z. ...
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Zusammenfassung Hintergrund Die vorliegende Studie untersucht, in welchem Ausmaß Schulen Maßnahmen der Gesundheitsförderung und Prävention während der COVID-19-Pandemie umsetzen. Von besonderem Interesse sind hierbei Unterschiede nach demografischen Variablen, Schulform, Bundesland und die Beteiligung an Landesinitiativen der Gesundheitsförderung. Methodik Im Rahmen des COVID-Health-Literacy-Netzwerks wurde von März bis April 2021 eine Onlinestudie mit 2186 Schulleitungen in Baden-Württemberg, Hessen, Niedersachsen und Nordrhein-Westfalen durchgeführt. Der Umsetzungsstand der COVID-19-bezogenen schulischen Gesundheitsförderung und Prävention wurde mittels eines eigenentwickelten Instruments untersucht. Nach Analyse der faktoriellen Struktur des Instruments erfolgten uni- und bivariate Auswertungen. Ergebnisse Es lassen sich 3 Dimensionen des Umsetzungsstandes der schulischen Gesundheitsförderung identifizieren (1. COVID-19-bezogene Unterstützung der Schüler*innen, 2. Gesundheitsförderliche Gestaltung von Lehr‑, Lern- und Arbeitsbedingungen, 3. Prinzipien der Gesundheitsfördernden Schule). Eine geringe Umsetzung liegt für Aspekte der Lehr‑, Lern- und Arbeitsbedingungen sowie für Partizipation und die Kooperation mit schulexternen Akteuren vor. Signifikante Unterschiede des Umsetzungsstands ergeben sich zugunsten von weiblichen und älteren Schulleitungen sowie Grundschulen. Außerdem zeigen sich nicht homogene Unterschiede nach Bundesland. Differenziert nach Teilnahme an einem Landesprogramm findet sich lediglich für Schulen mit Zertifikat im Bereich Gesundheitsförderung ein höherer Umsetzungsstand. Diskussion Die Ergebnisse geben Hinweise darauf, dass die COVID-19-Pandemie für Schulen ein disruptives Ereignis darstellt, welches die Umsetzung schulischer Gesundheitsförderung erschwert. Vor allem gesundheitsförderliche Arbeitsbedingungen, Partizipation und Kooperation sollten in den Fokus genommen werden.
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Objetivo: Avaliar a eficácia de um programa de educação em saúde em escolares direcionado à prevenção de doenças helmínticas sob a perspectiva de um processo de educação em saúde com conhecimentos e habilidades que favoreceram as mudanças e melhorias da qualidade de vida. Método: Trata-se de uma pesquisa com delineamento epidemiológico de intervenção do tipo ensaio clínico profilático. Resultados: O estudo foi realizado em uma escola da rede pública do município de João Pessoa/Paraíba, sendo incluídas na coleta de dados adolescentes com idade entre 10 e 14 anos, matriculadas nos 6º e 7º ano do Ensino Fundamental II. Os resultados apontam que após a realização de uma intervenção de educação em saúde o número de acertos relacionados à transmissão das doenças foi: Ascaridíase (86,7%) e Ancilostomíase (87,4%). Após um ano da intervenção educativa os resultados se mantiveram positivos para Ascaridíase e Ancilostomíase (74,1%) com significância estatística. A utilização de diversas metodologias ativas na comunicação com o público-alvo se apresentou como significativa para apreender a atenção e construir os espaços de interação para potencializar o compartilhamento de conhecimentos. Conclusão: Os resultados apontam que o modelo proposto de intervenção em educação em saúde mostrou-se efetivo nos momentos após a intervenção e um ano de sua realização. O baixo custo para realização das intervenções propostas fortalece a indicação de sua utilização, tendo em vista a fragilidade de acesso a materiais que algumas escolas públicas encontram. Assim, a utilização de metodologias ativas pode ser recomendada para intervenções em educação em saúde para escolares nessa faixa etária.
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This paper presents the qualitative process findings from an evaluation of a school-based performing arts programme, ‘Rock Challenge’. Rock Challenge aims to promote healthy life styles ‘by building resilience amongst young people involved’. The research aimed to capture the experiences and perceptions of young people’s involvement in the programme, particularly in relation to the concept of the ‘drug-free high’, support offered throughout the programme and participants’ response to Rock Challenge as a drug-prevention initiative. Findings from the study suggest young people felt very positive about their involvement and, in particular, valued the skills and experiences associated with organising a performance, team-working, developing confidence, friendship, fun and excitement. The excitement felt during dance rehearsals and the live performance was associated with the concept of a ‘drug-free high’, feeling good in the absence of drugs and alcohol, and was seen as a key benefit of the programme. While support from teachers and families was perceived as high, difficulties were identified in the recruitment of males and students vulnerable to substance misuse and recommendations are made for improvement. The health promotion opportunities for school nurses and other public health practitioners and personal, social and health education co-ordinators are highlighted.
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This article discusses the findings from a case study focusing on processes involving pupils to bring about health-promotion changes. The study is related to an EU intervention project aiming to promote health and well-being among children (4–16 years). Qualitative research was carried out in a school in the Netherlands. Data sources include project documents, interviews, and observations. Thematic analysis was carried out combining the different data sources. The case study shows that, if given sufficient guidance, children can act as agents of health-promoting changes. The main arena for youth influence was the pupil council. Pupils were meaningfully involved in two actions, which targeted road safety around the school and a playground for a disadvantaged community near the school. A clear framework was provided, which delineated the participation room for pupils at every stage. The main goal of participation was construed as the development of students' capacities to actualize their ideas. The pupils were positive about their involvement. Their experience with active participation seems to have empowered them, giving them the feeling of ownership, efficacy, and achievement in working with "real-life" problems.
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The article outlines two different paradigms which influence school health education. The first of these is the moralistic paradigm which is dominant in many current health education programmes in schools. It will be argued that the moralistic and totalitarian paradigm may actually be an obstacle for developing a demo- cratic school in a democratic society. The second paradigm focuses on democratic health educa- tion and is advocated in this paper as a valuable alternative to the moralistic paradigm. An over- view of the major characteristics of the two paradigms is followed by an analysis of several concepts which characterize democratic health education, including 'action competence', 'action' and 'holism'. These concepts illustrate that health and environment have to be closely linked in teaching if students are to acquire a coherent understanding of the dynamics behind health issues and health problems. Finally, the 'IVAC approach is suggested as a way of developing action competence in relation to health and environmental issues. Experiences and examples from the Danish Network of Health Promoting Schools are used to illustrate the thesis presented in this paper.
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Purpose There is increasing recognition of children's abilities to speak for themselves. School democracy, as demonstrated by genuine participation, has the potential to benefit both teachers and students; leading to better relationships and improved learning experiences. The aim of this study is to investigate whether participation in schools in Ireland is linked with perceived academic performance, liking school and positive health perceptions. Design/methodology/approach Data were collected via self‐completion questionnaires from a stratified random sample of 10,334 students aged 10‐17 years in Irish schools. The questions included encouragement to express their views in class, participation in the organisation of school events; taking part in making school rules; liking school, perceived academic performance, self‐rated health, life satisfaction and self‐reported happiness. Associations between school participation and other measures were expressed by odds ratios from logistic regression models, conducted separately for girls and boys. Findings More than 63 per cent of participating students reported that they were encouraged to express their views in class, 58 per cent that they were involved in organising school events and 22 per cent that they had been involved in making school rules. All forms of participation were lower among older students. Participation in school was significantly associated with liking school and higher perceived academic performance, better self‐rated health, higher life satisfaction and greater reported happiness. Research limitations/implications These data are all cross‐sectional and relationships cannot imply causality. Practical implications These findings underscore the relevance of school participation for students in Ireland. Originality/value The paper illustrates that, in general, positive relationships between school participation and health and wellbeing are demonstrated among Irish children.
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Multicomponent interventions are recommended for health behavior change among adolescents. However, it is difficult to disentangle the effects of multiple intervention components. This article reports outcomes associated with varying levels of exposure to a school-based nutrition intervention, Teens Eating for Energy and Nutrition at School (TEENS). Four incremental exposures were possible: (1) control group, (2) school environment interventions only, (3) classroom plus environment interventions, and (4) peer leaders plus classroom plus environment interventions. Patterns suggesting dose response were observed, with peer leaders reporting the largest increases in fruit, vegetable, and lower fat food consumption. Students exposed to classroom plus environment interventions also improved, whereas students exposed only to school environment interventions showed trends toward choosing lower fat foods and declining fruit intake and no change in vegetable intake. Control students' choices remained stable. Future studies may investigate mechanisms for peer leaders' changes, maximizing curriculum effectiveness, and improving environmental interventions.
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The Research in Participatory Education Network (RIPEN) was initiated by the Research Programme for Environmental and Health Education at the Danish School of Education, University of Aarhus, in 2003. It embraces a broad spectrum of researchers, scholars, students, and practitioners of participatory education, working in or from Europe, North America, Africa, and Australasia. Given the international scope of the network and the range of interests it now has, as initiators and early participants in the network the editorial team invited RIPEN to discuss what a critical perspective on participatory approaches to education might mean for education and the environment, health and sustainability, and how network members might research and substantiate their claims and ar guments. Following the introductory chapter on the scope of this collection, 19 chapters illustrate the contributors’ responses to that invitation. Our focus on critical perspectives was prompted by earlier work by Majid Rahnema in Wolfgang Sachs’s (1992), Development Dictionary. Critiquing concepts of participation in a volume that set out to stimulate cultural, historical, and anth- pological debate on the key concepts of development, Rahnema (p. 126) wrote: Participation, which is also a form of intervention, is too serious and ambivalent a matter to be taken lightly, or reduced to an amoeba word lacking any precise meaning, or a slogan, or fetish, or for that matter, only an instrument or methodology.
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Health and Modernity The Role of Theory in Health Promotion David V. McQueen, Centers for Disease Control and Prevention, Atlanta, Georgia Ilona Kickbusch, Federal Office for Health, Bern, Switzerland and Louise Potvin, Universit de Montral, Canada Jrgen Pelikan, University of Vienna, Austria Laura Balbo, University of Ferrara, Italy Thomas Abel, University of Bern, Switzerland Pandemics, substance abuse, natural disasters, obesity, and warfare: the line that once separated health crisis from social crisis no longer exists. Yet while social theories are implied in today's public health arena, they are rarely acknowledged. Now an international panel of leaders in world health explores this vital but understudied aspect of health promotion. Health and Modernity proceeds from the thesis that contemporary health promotion is, by definition, inextricably linked to its social context. The authors discuss global challenges in terms of cultural capital, risk and causality, systems theory, and the dynamic between individual and community. In the process, they define an entity that:-Understands the centrality of health to all areas of human life-Is committed to equity in access to health-promoting resources-Applies a multidisciplinary approach to public concerns-Looks beyond quick fixes and simple answers to complex issues-Employs a variety of political and social agents to accomplish health objectives-Is dedicated to empowerment, facilitation, and inclusiveness The insights found in Health and Modernity are certain to raise the level of debate among professionals, researchers, and the academic community in the global/public health and health promotion fields. This visionary volume guides readers from the immediacy of doing toward the deeper meaning that makes such doing possible. © 2007 Springer Science+Business Media, LLC All rights reserved.
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This paper presents a holistic model of the health promoting school and a panoramic framework for evalution. The framework is board, acknowle dging the range of national settings in which health promoging schools are being developed, and draws attention to the emphasis on context and process rather than outcomes. The conceptual model is applied to the European Network of Health Promoting Schools (ENHPS), where the same forces may be at work in relation to the innovation but operate in different ways and with different degrees of strength. The paper recommends a selective approach to evaluation which will serve specific audiences and decision making needs.
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Purpose With the aim of contributing to the evidence base on school‐based health promotion, the authors discuss the outcomes and processes of a European intervention project aiming to prevent obesity among children (4‐16 years) and promote their health and well‐being, titled Shape Up: a school‐community approach to influencing determinants of healthy and balanced growing up . Design/methodology/approach Multiple case study research was carried out in five schools in five EU countries. Data sources included project documents, interviews, and observations. Narrative qualitative cross‐case analysis was carried out following the single case analyses. Findings The study showed that, if given sufficient guidance, pupils can act as agents of health‐promoting changes on both school and local community level; they were involved in actions which improved school policies, provisions and affordances for healthier diet and regular physical activity. The study identified three forms of participation, each with a different level of pupil involvement and agency. Research limitations/implications The study is qualitative, based on five single cases and cross‐case analysis; this research design implies caution related to extensive non‐contextualised generalisation of the findings. However, valuable implications for research and practice can be drawn, especially in relation to structural barriers for participatory health promotion. Originality/value The paper is of value for researchers as well as practitioners in the field, particularly those interested in eco‐social models of health, whole‐school approaches to health promotion and pupil participation. The study's specific value is in the systematic qualitative cross‐case analysis, which contributes to the research rigour and allows for situated generalisation.