Report of the ‘Health in All Policies’ Focus Area Group on: EDUCATION & HEALTH Title: Report of the ‘Health in All Policies’ focus area group on education & health Date: July 2011 Authors: Noëlle Cotter (Institute of Public Health in Ireland), Owen Metcalfe (Institute of Public Health in Ireland), David Ritchie (NHS North West Health, UK) This publication arises from the Crossing Bridges project (2009 12 23), which has received funding from the European Commission, in the Framework of the Health Programme Contents 1.1 Introduction Health in All Policies – intersectoral working Executive Summary Health and Education Overview of Research Process Case Studies 11 12 5.1 12 The Netherlands The M@ZL project 5.2 Germany 13 HiAP overview National Centre on Early Prevention (NZFH) 5.3 North West England 15 HiAP overview Nursery Nutrition and Food Provision in Liverpool Smoke and Mirror Initiative 5.4 Republic of Slovenia 18 HiAP overview Model for Healthy Lifestyle in School National School Nutrition Programme 5.5 Hungary 21 HiAP overview Smoking Prevention Programme in Kindergartens & Schools Health Promotion Pilot Project against Segregation LOGO – Complex Youth Service System 5.6 Poland 25 HiAP overview Joyful School ‘Radosna szkoła’ I know what I eat ‘Wiem, co jem’ 5.7 Republic of Ireland 29 HiAP overview Food Dudes: A primary education initiative to promote healthy eating Green Schools Ireland: Focus on Active Travel 5.8 Veneto Region, Italy 32 HiAP overview Integrated educational package on the prevention of AIDS and STIs in secondary schools National Project for the Promotion of Physical Activity (NPPPA) What worked for HiAP, why and how? Results References Acknowledgement 36 37 41 42 Introduction Crossing Bridges is an 18 month project that builds on work undertaken in the EC co-funded 'Closing the Gap' (2004-2007) and 'DETERMINE' (2007-2010) projects, and will complement the 'Joint Action on Health Inequalities' (2011-2014), to advance the implementation of Health in All Policies (HiAP) approaches in EU Member States It will this by developing evidence led methods and building capacities, as part of the overall mission to improve health equity within and between states Health in all Policies (HiAP) is an approach which ensures that all policy considerations, in particular those outside of the immediate remit of health and healthcare policy, take account of the potential to contribute to population health A HiAP approach demonstrates an understanding that determinants of health are principally controlled by sectors other than health Dahlgren and Whitehead’s diagram (figure below) is frequently cited to demonstrate the multi-faceted nature of influences on population health Figure 1: Dahlgren, G Whitehead, M (1991) Policies and strategies to promote social equity in health, Institute of Futures Studies, Stockholm 1.1 Health in all Policies and inter-sectoral working Recognising that ‘health’ goes beyond ‘health care’, and that health is often determined in sectors outside of health has taken time within European policy-making but incremental progress is being achieved, in particular with regard to the links between education and health (Grossman, 1975; Lleras-Muney, 2006; cited in Suhrcke et al, 2011) and the work of the World Health Organisation and the Marmot Review have made significant contributions in this regard However, in accepting this approach in theory, or acknowledging it as a good idea does not mean that the HiAP approach is diligently followed The implementation of Health Impact Assessments (HIA) in several European jurisdictions to health-proof policies during formulation shows some improvements in this area However HIA is generally not a statutory requirement but health impacts are taken into consideration within other statutory impact assessment processes, for example Strategic Environmental Assessment (European Directive 42/EC/2001) The intent of ‘Crossing Bridges’ is to progress this and explore what exactly is it that ensures a HiAP approach, or indeed what are the barriers The method used was to explore case studies across Europe in the areas of transport and planning, and education where health was explicitly or implicitly addressed during the policy-making process and was an intended outcome or unintentional by-product Stahl et al (2006) have outlined what is needed for a HiAP approach and ‘Crossing Bridges’ intends to learn more about embedding this action Action and implementation of HiAP is dependent on the availability and existence of human resources and knowledge of public health issues, health impacts and social determinants Focus on HiAP therefore needs to be set in a long-term and institutional context This requires a sufficient basis of training and research on matters of public health, health policy and determinants of health It also requires that action on HiAP has sufficient priority and a critical mass of support within the government and among policy-makers, including nongovernmental organizations (NGOs) This is of particular importance in the context of tackling more complex and long-term problems and policylevel issues (Stahl, T et al (2006: 17) Health in All Policies: Prospects and potentials Ministry of Social Affairs and Health, Finland) ‘Closing the Gap’ and ‘DETERMINE’ both worked towards increased awareness, knowledge and willingness to implement a HiAP approach ‘Crossing Bridges’ intends to drive this forward through capacity building knowledge Thus far it is known that there are six principal areas of capacity building and awareness-raising to encourage a HiAP approach as identified in the ‘DETERMINE’ process:       policy development partnership development skill development organisational development development of the information base awareness raising In general, a partnership or inter-sectoral approach is accepted as best practice in policy-making circles but this can be difficult to implement Some policies merge well, for example as will be shown in the case studies, beneficial environmental and health outcomes can be positively interwoven when encouraging people to walk or cycle Even in cases when policies take a HiAP approach, there are other unknown variables that could negatively impact, or neutralise the intended positive effects For example, healthy eating programmes for school children, advertising controls, food labelling and nutritional advice, could be counteracted by actions in the home that are influenced by policies and practices in other domains (Sihto et al, 2006) Policies can also directly clash; as illustrated in Jousilahti’s (2006) demonstration on how the EU’s common agricultural policy could counteract attempts to reduce cardiovascular heart disease across Europe Moreover, particularly given the recent economic climate, ring-fenced budgets can support silo views At a grassroots level, such as among the community and voluntary sector, there has been a greater move towards inter-agency cooperation and inter-sectoral working Himmelman (2004) developed a matrix to demonstrate the differences between various levels of inter-sectoral working using definitions from a healthcare setting; ranging from a more informal basis to full integration However, this is frequently reliant on a ‘champion’, a person who wants to drive forward multisectoral and integrated working, or alternatively is reliant on a top-down instruction Use of a ‘champion’ or a direct top-down order to implement integrated working may also be less complex to implement in terms of direct service provision than at the policy-making level where there are more complex competing interests; in particular ‘champions’ of other issues working in diverse directions to HiAP Box Matrix* of Coalition Strategies for Working Together Networking Coordinating Cooperating Collaborating Exchanging information for mutual benefit Exchanging information for mutual benefit, and altering activities to achieve a common purpose Exchanging information for mutual benefit, and altering activities and sharing resources to achieve a common purpose Exchanging information for mutual benefit, and altering activities, sharing resources, and enhancing the capacity of another to achieve a common purpose Relationship Informal Formal Formal Formal Characteristics Minimal time commitments, limited levels of trust, and no necessity to share turf; information exchange is the primary focus No mutual sharing of resources necessary Moderate time commitments, moderate levels of trust, and no necessity to share turf; making access to services or resources more userfriendly is the primary focus No or minimal mutual sharing of resources necessary Substantial time commitments, high levels of trust, and significant access to each other’s turf; sharing of resources to achieve a common purpose is the primary focus Extensive time commitments, very high levels of trust and extensive areas of common turf; enhancing each other’s capacity to achieve a common purpose is the primary focus Moderate to extensive mutual sharing of resources and some sharing of risks, responsibilities, and rewards Full sharing of resources, and full sharing of risks, responsibilities, and rewards Definition Resources Source: Himmelman (2004) *Himmelman states that in reviewing this chart, it should be borne in mind that these definitions are developmental and, therefore, when moving to the next strategy, the previous strategy is included within it None is superior; rather, each may be more or less appropriate In a similar vein to the Crossing Bridges project, the Public Health Agency of Canada published Crossing Sectors – Experiences in intersectoral action, public policy and health (2008) This was prepared in collaboration with the Health Systems Knowledge Network of the WHO’s Commission on Social Determinants of Health and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) This, and an associated publication Health Equity through Intersectoral Action: an Analysis of 18 Country Case Studies (2007), intended to similarly identify what ensures intersectoral action to promote health equity through an analysis of case studies from high, middle and low income countries Their results are parallel to those found in this report focussed on EU member states There is no over-riding paradigm transferrable to each context; rather there are a series of strategies based on the existing situation that appear to facilitate intersectoral action These identified strategies will be further discussed in the final section to combine the evidence for proposals for developing HiAP Norway has been particularly progressive in attempting to ensure a HiAP approach and in 2009 the World Health Organisation (WHO) published an outline for how this HiAP process was developed (see Strand et al, 2009) What can be learned from the Norwegian experience is that the political, policy, and problem streams merged to progress a HiAP approach The mechanisms that appear key and potentially universal to this positive HiAP outcome, that could be applied elsewhere are:      Development of a strong evidence-base, coupled with clear communication of the outcome messages A willingness among the policy developers and makers to partake in this process based on national policies of social inclusion and equity Cooperation without cynicism between research, NGO and civil service actors Formal structures to make the links and communicate the health inequity perspective in seemingly unrelated policy arenas Despite the creation of these new structures and ‘policy entrepreneurs’, existing infrastructures and budgets to be used to ensure embedding of the HiAP process, rather than as an add-on The common theme across these five points is the need for seamless sharing of knowledge and skills across the policy spectrum which includes an abandonment of silos and breaking down the barriers between esoteric knowledge What also potentially contributed to this relatively rapid uptake of a HiAP approach in Norway was political willingness Although this may not be present in all countries, this can be developed by highlighting that HiAP is a sensible approach to ensuring other key manifesto and policy promises are fulfilled Demonstration of financial savings that could potentially be made by health equity is controversial; there are moral reasons for health equity and the arguments should not be reduced to cost benefit analysis However, in the absence of interest in health equity and particularly in light of the current straitened times financial savings may be the most appealing method to encourage interest Executive Summary The influence of education on health status has been well-documented; particularly in the context of the social determinants of health Educational attainment can frequently be used as a proxy for socio-economic status which both in turn can be used to predict health outcomes A recent WHO systematic review (2011) also noted the influence of health on educational outcomes, however causality cannot be assumed In addition to the relationship being complex, it can also be difficult to state definitively the impact or correlation of education or health interventions on each other It can be a challenge to measure or evaluate the long term effects of, e.g early years interventions, and rather measurement focuses on the more narrow immediately apparent indicators Despite these limitations, it is accepted that education plays a significant role in the social determinants of health and that the relationships between health and education are inherently linked Eight countries/regions submitted seventeen ‘health and education’ case studies to the ‘Crossing Bridges’ project with the intent of providing policies/projects/initiatives as examples to inform capacity-building for a ‘health in all policies’ agenda Central to this was the question of what made a ‘health in all policies’ approach succeed or prove challenging in an educational policy context Case studies were diverse; seven dealt with nutrition and/or physical exercise, five with early years developmental health (including neglect of children and breastfeeding) and five dealt with risk behaviours such as school drop-out, sexual activity, tobacco and other substance misuse These could be divided into two principal categories; encouraging healthy lifestyles and positive health outcomes for young children, and avoiding risk behaviours that would impact on older children’s health These case studies are summarised in the main report, and a separate annex provides the original case studies sources These case studies not claim to be representative, and identification of case studies did not involve systematic country/region reviews but rather deferred to the local knowledge of work group partners A diverse and rich body of data was gathered and key points to develop a health in all policies agenda are outlined below:       Political expediency: getting buy-in at the highest levels of policy formation may be ideal if it is not already present If not present, the importance of health to multiple policy agendas should be highlighted Established regulations and relationships: Frameworks for inter-sectoral work are very important to facilitate this process, however relationship-building within these frameworks cannot be legislated for – this may be where higher ranking staff can play a role in ensuring cooperation Shared budgets and agendas facilitate flexibility and much successful intersectoral collaboration There is a need to move beyond rhetoric to systematic action Communication: Learning to utilise other stakeholders’ knowledge and expertise may require engagement on their own territory using language they are familiar with in their own domains The complexities of other sectors and systems must be recognised and not shied away from The usefulness of new technologies for information dissemination, sharing ideas and attracting attention should not be under-estimated Implementation: Implementation is needed at all levels and although an impetus may originate from the top-down or bottom-up, engagement and buy-in at all stakeholder levels is needed and useful for tapping in to expertise Evidence and evaluation: Having an evidence-base for the policy, project or programme assists the strength of the argument for implementation and ongoing monitoring and evaluation not only ensures constant vigilance and a strong evidence-based, but also keeps the project in the spotlight Sustainability: Keeping the costs low, reinvention and expansion, and ensuring the least disruption to staff assists the sustainability of programmes Health and Education In 2011 the WHO published a systematic literature review of the impacts of health and health behaviours on educational outcomes in high-income countries This review noted that much of the literature available in this area focuses not only on developing countries, but also on the impact of education on health This review intended to look at evidence from developed countries as well as the relationship from the opposite direction; if better health leads to a better education Specifically the authors focussed on the following:   Does poor health during childhood or adolescence have a significant impact on educational achievement or performance? Does the engagement of children and adolescents in unhealthy behaviours determine their educational attainment and academic performance? Based on the evidence reviewed, some of the principal findings included the following:      Overall child health status positively affects educational performance and attainment For example, reviewed studies turned up evidence that good health in childhood was linked to more years in education, that sickness significantly affected academic success and sickness before age 21 decreased education on average by 1.4 years There are negative effects on educational outcomes of smoking and poor nutrition that may outweigh the negative effects of alcohol consumption or drug use There appears to be a significant positive relationship between physical exercise and academic performance Obesity and being overweight are negatively associated with educational outcomes Sleeping disorders, anxiety and depression may impact on educational outcomes The WHO systematic review outlines that there are significant links between education and health, but these can often be difficult to definitively establish and causality frequently cannot be assumed These authors also outline elsewhere (2005) that the direction of a relationship can move in both directions – better health can lead to better educational outcomes, but in addition better education can lead to better health Given the rigorous nature of academic research and problematic research artefacts such as selfreported health, causality and unknown and unquantifiable influences, it can be difficult to establish clear links between health and education although it may be otherwise apparent that there is a logical correlation Therefore, research and advocacy is in a bind of wishing to remain loyal to a rigorous academic process which may only be achieved by focus on variables with very clear relationships to health while wanting to move away from these clear measurable correlations For example, the clearest way of showing links between health and education may be through evaluation of an intervention and that intervention will have a clear, defined and measurable relationship to health However this will generally mean a focus on a lifestyle factor rather than a more abstract policy ‘intervention’ that appears to have little in common with health policy, and in fact may have multiple other positive impacts on health that are not apparent within the formal educational spectrum In formulating the research question for ‘Crossing Bridges’ work group partners, certain factors had to be taken into account; the resources available, as well as the necessity for a clearly formulated question This ensured a greater focus on policies from across Europe that had apparent links between health and education rather than these more obtuse policies However, work group partners have provided a wealth of case studies which will inform the capacity-building process These include:     Nutritional programmes Physical exercise and developmental programmes Mental and physical well-being programmes Tobacco and alcohol control programmes 10     Simple and clear aim – to re-orientate children’s eating habits The programme is well-prepared and is evidence-based providing support for arguments beyond nutritional benefits, to improved concentration and behaviour in the classroom Co-financing of lunches for poor children without bureaucracy and stigma Academic involvement and in return there are professional benefits to their involvement Evaluation: Academic involvement has meant a lot of research and ongoing production of reports Monitoring is on the basis of a self-assessment questionnaire submitted via the website describing the extent of changes However, there are some inconsistencies between this information and what is happening on the ground An independent evaluation by the Warsaw University of Life Sciences is underway and will be released later in 2011 This evaluation appears to be particularly robust as it will include information about schools that both took part and refused to take part 28 5.7 Republic of Ireland HiAP overview Health in all policies is not on a statutory basis in Ireland and it is not a recognised policy objective Despite this, health is considered a priority and is often the basis of, or an important factor within the policy making arena The Chief Medical Officer is currently putting together a public health strategy which is likely to embed the idea of health promotion and HiAP in Ireland’s policy agenda HIA is identified as a tool to support the development of healthy public policy In the Republic of Ireland, Quality and Fairness, the public health strategy (2001), states HIA will be introduced as part of the public policy development process The Institute of Public Health in Ireland (IPH) is funded by the Departments of Health in Northern Ireland and the Republic of Ireland and a key strand of work is to build capacity for HIA across the island of Ireland IPH undertook a baseline study of HIA in 2001 which indicated there was ‘little knowledge of HIA as a term or concept outside of a core group of organisations and workers engaged in high-level policy and service development’ In 2009 further research was undertaken to determine how HIA is being used in practice to support a health in all policies agenda This recent study showed that across Ireland, HIA is increasingly being seen as a tool to facilitate healthy public policy This has been supported by developing appropriate tools and guidance, developing and providing appropriate training and capacity building, providing networking opportunities for those interested in HIA and conducting HIAs Food Dudes: A primary education initiative to promote healthy eating The Food Dudes programme was developed by psychologists from University of Bangor, Wales, and launched in Ireland in 2005 The intention of this programme is to promote sustained healthy diets and a healthy eating culture in young children in school to address obesity throughout the life course The EU Commission provides 50% of the funding, the fresh produce industry provides 30%, and the Department of Agriculture and Food provide the remaining balance of 20% of the funding The programme is managed by Bord Bia – the national food board The programme provides fruit and vegetables to clustered schools over a short intensive period, which is supplemented by cartoon figures promoting nutritionally beneficial options Children are rewarded for fruit and vegetable consumption, and the programme is extended by encouraging children to bring their own fruit and vegetables to school every day in Food Dudes containers This preferred behaviour is monitored and encouraged through wall charts, certificates and further rewards Fruit and vegetable consumption is scientifically proven to be maintained in the longer term with this combination of produce provision, cartoon promotion and rewards Healthy eating can also be incorporated into other areas of the primary curriculum alongside this programme National roll-out began in March 2007 and Food Dudes is now serving approximately 1,400 schools Early evaluations were positive and national evaluations are ongoing In 2006 Ireland’s Food Dudes programme won a WHO award for best practice at a European Ministerial Conference on Counteracting Obesity Developed by: An agency of the Department of Agriculture and cooperation was received from teachers and the private sector Cooperation: Departments of Education, Social Welfare, Health, also teacher unions, principal teachers’ networks, school boards of management 29 Context: The requirement to promote Irish produce, and to publicly expand the Department of Agriculture’s mandate beyond farming and into the food sector Conceptual approach: Although the origins were in the agriculture sector, the approach is now in health promotion Keys to success:         An academic evidence base and rigorous evaluation Presence of a champion Communication; and not requiring particularly large investment by other sectors Personal relationships between civil servants in different sectors It was easier for a semi-State body to promote this scheme as it is considered unbiased – it would have been far more difficult for the private sector to market directly to children in schools without suspicion Similarly, the Department of Education used their headed notepaper in informing schools about the Scheme which lent credibility and enabled easier access The Scheme could be embedded in the curriculum – links were made with various subjects Cooperative funding; the Department of Education paid for the substitute teachers while others were attending training sessions Sustainable – methods are currently being explored to ensure continuation of the programme despite financial constraints Funding is now being received through the EU School Fruit Scheme Schools have used the Scheme as a basis for introducing healthy eating programmes Evaluation: The pilot phase involved a considerable scientific evaluation process (weighing of the food for each pupil, monitoring how much was eaten etc.).6 There have been multiple evaluations with parents, teachers, and coordinators, there are also annual evaluations Between 2005 and 2007 Bangor University developed a questionnaire that was used and analysed by University College Dublin (UCD) However as the results were so consistent UCD said it was not worth their while and a waste of their researchers’ time doing them A commercial market research company was then engaged to this job However UCD will again be evaluating the scheme as an independent evaluation is needed for the EU School Fruit Scheme UCD will be developing the survey Green Schools Ireland: Focus on Active Travel The Green Schools Programme was first piloted in Ireland in 2005 through the Dublin Transportation Office The national roll-out has been ongoing since 2008 and is now operated through the National Transportation Authority and managed by an environmental group – An Taisce This programme is run throughout Europe (eco-schools) and primarily has an environmental focus However, in terms of travel it has a strong ‘active travel’ – walking and cycling – framework Each year walking-toschool-days are organised and since 2008 5,282 students have received bicycle training and 2,230 bicycle parking spaces have been installed in schools across the country In addition, the scheme provides training on bicycle maintenance and undertakes cycle route audits By the end of January 2011 3,500 primary, secondary and special needs schools were involved This equates to 83% of all schools nationally In developing this active travel aspect of the wider programme, other positive elements aside from environmental benefits were identified and are a focus of the programme Details of academic publications arising from these scientific evaluations and other evidence available on line [http://www.fooddudes.ie/research_publications.pdf accessed 18 October 2011] 30 These include preventing obesity, making children fitter, and encouraging safety However, the Green Schools initiative did not develop with any healthcare or health promotion specialists direct input The Green Schools programme ties in with Ireland’s first National Cycle Policy Framework (April 2009) which has an objective to “provide cycling-friendly routes to all schools, provide adequate cycling and parking facilities within schools and colleges, and provide cycling training to all school pupils.” There is the intent to introduce a mandatory national cycling proficiency programme for all school children in Ireland from primary through to secondary education Developed by: An Taisce, at the request of the Department of Transport Context: The wider programme of Green Schools An Taisce brought Green Schools to Ireland at a time when a waste management plan was being introduced and this was the first ‘strand’ of the green schools programme that was to be rolled out It has been a national programme for 13 years, and the strand that is of particular interest to Crossing Bridges – transport – was developed as a suggestion by the Dublin Office of Transport to An Taisce They had wanted to reduce congestion outside schools but had been unsuccessful and liked the Green Schools methodologies Therefore An Taisce couched it as more than a environmental project, but also as a safety project with a health element – reduce carbon emissions, reduce obesity and get fitter while making routes to schools safer and educating children how to cycle safely They used health as one way of selling ‘active travel’ Cooperation: An Taisce, Department of Transport, participating schools Conceptual approach: Environmental impacts Keys to success:         Integrated into existing programme of environmental interventions – good timing The presence of evidence-base and rationale – the Report of the Taskforce on Obesity (2005) demonstrated a need for such a programme Ability to demonstrate success with the pilot programme Add-on benefits in the areas of environmental improvement, health promotion and safety which were key existing policy agendas (waste management, traffic congestion, evidence from the obesity taskforce, and the national ‘smarter travel’ formulation to encourage more sustainable lifestyles) Captured the imagination of unintended recipients such as teachers and communities Has inspired forthcoming programmes to encourage a ‘lost generation’ to cycle As it was developed by an agency rather than a government department with sufficient resources, this may have enabled greater flexibility Surprising to find that it was not necessarily the presence of infrastructure or geographic location that encouraged success of the programme, rather it appeared to be more determined by engagement with key decision-makers No cynicism among involved groups, there was very genuine engagement Evaluation: Ongoing monitoring and evaluation of the programme throughout the school year (baseline through to end of academic year looking at the modal shift of the school commute), however health impacts have not been measured which would have been useful 31 5.8 Veneto Region, Italy HiAP overview At a national level, there are general objectives and fundamental principles of health, as well as ‘essential levels of health care provision’ However, it is the responsibility of the Regions to define the specific conditions and delegate local implementation to the Local Health Trusts and other structures The Regions are also charged with leading the evaluation and control of all projects and services as well as guaranteeing financial accountability In 2007 a ‘transversal programme’ was approved by the Prime Minister in agreement with the independent regional and provincial governments entitled Gaining Health: encouraging healthy choices as part of the European Framework launched by the WHO in 2006 for chronic disease prevention and control strategies This has the intention of preventing and changing unhealthy behaviours which are the main risk factors for major non-communicable diseases and have the greatest epidemiological relevance to public health (cardiovascular diseases, cancer, diabetes, chronic respiratory pathologies, musculo-skeletal and gastro-intestinal illnesses, mental health problems) It recognises that most of the effective actions to prevent such risk factors are outside the domain of the national health system One of the principal aspects of this programme is collaboration among the various ministries and protocols of agreement have also been signed with trade unions and business associations Integrated Educational package on the Prevention of AIDS and STIs in secondary schools This project is part of a regional7 initiative aimed at the prevention of AIDS and STIs among secondary school students Recent research reveals that the link between drug addiction and STIs is decreasing whereas there is an increase in the number of cases transmitted through heterosexual intercourse For this reason, the focus of research activity is shifting from “risk groups” to “risk behaviour” The overall objective of the project is to reduce the incidence of HIV and STIs among school-going adolescents (14-18) by providing a targeted education programme addressing the risk perception of the students The project was launched in 2000 and was implemented initially as an experimental project in the territory of four Local Health Trusts (2000-2003) It was then extended to other Local Health Trusts and has undergone several evaluations The project is currently being adapted to integrate a new training module to include an in-depth understanding of anatomy, physiology, sexual and emotional life The training module entitled “The Integrated Educational Package” consists of two meetings conducted by specifically trained health professionals (psychologists, GPs or trained nurses) It uses interactive communication and information tools to improve knowledge about sexual and reproductive health, to reduce stereotypes and prejudice, to increase assertiveness and to better understand prevention options The project was developed by the Veneto Regional Department of Prevention and implemented in partnership with the Local Health Trusts and with the secondary school administrations involved in the project The direct The Veneto Region is responsible for providing health and social services to a population of approximately 4.7 million inhabitants through its 21 Local Health Trusts and two Hospital Trusts It also plays a leading role in the national healthcare resources planning, with a strong emphasis on policy concerns In recent years, the progressive strengthening of regional powers to deliver finance and healthcare has seen a parallel delegation of managerial authority to the Local Health Trusts Local Health Trusts are unique in the Veneto Region in that they provide both healthcare and social services in an integrated manner to the population This project has been managed by the Service for Health Education of Local Health Trust N° 13 in Dolo 32 management of the project was undertaken by the Service for Health Education of Local Health Trust N° 13 in Dolo Initiated by: The Regional Service for Prevention and Health Education developed a draft proposal in 1999 which over the next year was further elaborated in collaboration with STD experts and Local Health Trusts Developed by: Four Local Health Trusts, the Regional Centre for Health Promotion, secondary schools, additional Local Health Trusts in the further development of the project Context: Recent trends in the increase of HIV infection; in the Veneto Region there are an average of 100 new cases each year Research has also pointed to increases attributable to heterosexual intercourse rather than drug use, as well as other forms of STDs In addition, there is a National Regulation (DPR 309, 1990) for collaboration between health and education for prevention and health promotion with regard to illegal drug use and addition Conceptual approach: Health promotion Keys to success:           The schools are not financially or organisationally burdened and the project activities are not too time-consuming Popularity with schools – indicated by the increasing numbers taking part An identified need for such a programme supported by WHO and UNICEF publications, as well as evidence from national and international research The established cooperation between Health and Education as well as National Regulation providing a legal and practical framework The inclusion of the programme into the three-year Regional Health Plan for Prevention The ability of the project to link a specific need of the Local Health Trusts with the secondary schools and National Regulation Consistent meetings between the Local Health Trusts and the schools Though developed at a policy level, ongoing stakeholder consultation was undertaken An ability to engage with the religious schools who initially were opposed to the programme Sustainability through the circular process of project evaluation (implementation, evaluation, planning etc) as well as the implementation of a ten year programme, the Integrated Educational Package, at the regional level Evaluation: Self-reported questionnaires, follow-up questionnaires and focus groups Short, medium and long term impacts are all quantified for the effectiveness of this programme 33 National Project for the Promotion of Physical Activity (NPPPA) This is a two-year project (concluding 31st July 2011) involving a collaboration between the President of the Council of Ministers (Department for Youth Policies and Sports Activities) and the Ministry of Labour, Health and Social Policies (Department for Prevention and Communication – Directorate General for Health Prevention) It is coordinated by the Department of Prevention of the Local Health Trust N° 20 in Verona and is implemented in six Regions in Italy The overall objective of the project is to increase physical activity focussing on normal everyday activities which are sustainable from an economic point of view and favours the use of public spaces The underlying consideration of the project is the awareness that physical activity can contribute to the prevention of chronic disease and can play, at the same time, a role in the process of social integration A drawback that could be identified for this case study is the potential presence of competing initiatives that could serve to overwhelm This is a large project with many different facets, to give a flavour of what this involves part of one of the initiatives, ‘Clever Kids’ targeting school children across all age cohorts is outlined below: Vado a scuola gli amici… camminando! (I’m off to school with my friends – walking) Target: Children attending primary school (ages - 10) The objective of this initiative is to encourage children to walk or cycle to school Where it is not possible to travel the full route from home to school by bicycle or on foot, parents or school buses have the option of transporting the children to a designated safe-area near the school where the children can complete the journey either by foot or by bike + movimento – TV = OK! (More movement, less TV = OK) Target: Children attending secondary school (ages 11 - 13) This initiative includes a number of different activities targeting children including (i) encouraging children to keep a diary to record the amount of physical activity they carry out in a period of one week and then calculate whether this corresponds to the required amount according to international standards (ii) “Urban Orienteering” aimed at increasing the awareness of children of the urban area both in and around their school and along the route from home and school (iii) information campaigns on simple ways and means of increasing physical activity Concorso Ragazzi in Gamba 2011 (Clever Kids Competition 2011) Target: Adolescents attending secondary school (ages 13 - 18) This was a competition aimed at secondary school students to award a prize for the best video message, story or picture aimed at other adolescents to promote physical activity or healthy eating habits or a combination of the two Developed by: Inspired by physical activity initiatives in Verona, the Veneto Region launched a regional programme against sedentary lifestyles and the promotion of physical activities The success of the Regional experience ensured a place for such initiatives under Gaining Health as discussed above Partners to this national programme include six regional authorities, the Italian Union of Sport for Everyone, two municipalities and one Local Health Trust At the local level, there are multiple partners including Local Health Trusts, school administrations, municipalities and municipal police forces 34 Context: Rising levels of obesity among children paralleled with increasing sedentary lifestyles represent a major public health challenge in Italy today Ten percent of the Italian National Health System budget is spent on costs associated with obesity Moreover, in Italy, in contrast to other European countries, sports or physical activity at primary and secondary level is limited and gyms are not a governing requirement for school buildings Conceptual approach: Health promotion, but environmental and safety elements also Keys to success:       A national programme, Gaining Health, within which this initiative could be developed An international evidence-base supporting such interventions, as well as national data The development at a local, regional and later national level, enabled ground-up stakeholder involvement It took advantage of existing resources, projects and networks already operating successfully in the area of the promotion of physical activity These were multi-dimensional interventions incorporating other policy objectives Sustainability – although the ‘National Project for the Promotion of Physical Activity’ will end in mid-2011, many of the individual initiatives have been integrated into regional health promotion plans Evaluation: There has not been a large scale evaluation, however parents, teachers and other experts were asked to complete questionnaires before and after the intervention Internationally established scales were used in these questionnaire designs In addition, impact indicators have been developed 35 What worked for HiAP, why and how? Case studies focussed on two key areas of HiAP in the educational field Firstly, developing early years’ interventions to promote better lifelong health outcomes for the population and secondly, focussing on ‘risk behaviours’ among teenagers and young people Overall the prevention of obesity through nutritional and physical activity programmes were the most common health impacts of case studies identified The most immediate positive impact for educators was more alert children in the classroom Medium term positive impacts included assisting children to negotiate peer behaviours and mainstreaming developmental markers on a more equitable basis For example by preventing peer pressure to smoke and by ensuring that children across socioeconomic groups are achieving developmental markers at the same stage and therefore progressing in their early education at the same pace Taking a longer-term view, better lifelong health outcomes over the entire life course were the anticipated positive impacts of these interventions across the full spectrum of case studies In these instances, health and education are natural partners; States invest in their educational systems on the understanding that the reciprocal benefits will not be evident for many years, and this mirrors many of the most important health outcomes from these interventions Therefore, although many of the interventions could be considered projects rather than policies, and many could be considered in the realm of health promotion rather than directed by education, this can be attributed to this close relationship between the domains of health and education What may be more difficult to achieve is to insert health into policy areas that are not natural partners; where prioritising health may negatively impact on the policy intent rather than complement it At the outset, certain key elements already well-established in the literature were expected to emerge, for example the presence of a champion or the importance of inter-sectoral and multidisciplinary working However, a good deal of additional detail and less obvious methods of incorporating ‘health in all policies’ emerged Results are presented below, and a number of practical suggestions and new questions are raised 36 Results The results discussed in this section are based on information derived from case studies considering health and education and therefore can only be strictly considered in this context However, it is feasible that these methods for propagating a health in all policies approach could be applicable in multiple sectors beyond education Political expediency A principal way of ensuring HiAP was undertaken in the examined case studies was to introduce suggestions or pilot programmes, or develop an advocacy role that would either put the topic on the political agenda or take advantage of what was already directly or indirectly under consideration Through achieving recognition at an elected representative level, the hierarchical layers beneath adopted the concept This could mean identifying routes into existing policy contexts within which health would bolster the agenda This trickle-down effect could also work, not only at elected official level, but among high-ranking civil/public servants This pressure to put health on the agenda could come from the bottom-up, achieving attention and funding to expedite the grassroots requests; in other words bottom-up to top-down Established regulations and relationships As outlined by the national/regional overviews of HiAP, existing frameworks or mandates, particularly those of inter-sectoral cooperation, are ideal situations However, discrepancies between what should and does happen may occur In spite of ineffectual or absent frameworks, inter-sectoral cooperation was evident in the case studies Frequently this appeared to be attributable to shared agendas rather than necessarily having to convince other sectors of the value of a particular endeavour Therefore, once shared agendas were established inter-sectoral cooperation and flexibility appeared to follow suit Tools or methods for such cooperation beyond initial recognition of common interests at a legislative/policy level may feel artificial However, intersectoral budgets can help to encourage relations in a practical way Many case studies had a health promotion agenda rather than an inter-sectoral agenda per se, however considerable networking and cooperation were required across the board as multiple agencies and individuals worked together to achieve their goals In many of the case studies, good relations between different sectors/agencies often in combination with the presence of a champion also proved essential to the development of the policy/project However, the presence of an enthusiast is insufficient and may result in patchwork or piecemeal implementation It may be necessary to consider how to develop a more permanent champion, or pseudo-champion role, perhaps by developing clearer communication channels to ensure identification of shared agendas is a necessity Communication Communication appeared to be a key element of all successful case studies, with regular meetings and updates between all parties Possibly to avoid fatigue, many of these meetings dwindled once the programme was established, but could easily be revived These lines of communication could prove essential for future developments of a health agenda across sectors Two other key forms of communication emerged from the case study analysis Firstly, the use of stakeholders and the recognition and value of various forms of expertise Stakeholders, in particular 37 people working at the coalface (for example, teachers, childcare centre workers, psychologists, counsellors), were regularly consulted and their feedback and experiences appear to have been valued and incorporated into policy/programme design While making the case studies more robust, this also facilitated buy-in at all levels In addition, many projects had in-built flexibility arising from evaluation processes so that grassroots-level tweaking could take place to facilitate a better version of programmes for the localised context Language may also be key to involvement and communication with others Frequently different sectors use different terminology and concepts to describe the same thing; learning, translating and understanding the language of other sectors that are being courted for involvement may prove crucial to embedding health in all policies Secondly, another key form of communication took place in the guise of the use of technology Social media tools, websites as well as teaching resources using new media and IT forms were used across multiple case studies and appear to be key to their success These forms of communication may not have directly contributed to a HiAP approach but rather to the advancement of the projects However, the use of these new media tools could be a method through which attention from other sectors could be gained and this interest harnessed Implementation Implementation of these case studies did not dictate that either a bottom-up or top-down approach worked best Instead, this was a far more fluid process and appeared to depend on the level of enthusiasm and appetite for such interventions rather than the direction, albeit bearing in mind that political expediency as discussed above could serve the top-down process to great effect The development of ideas in the policy space, with practical methods developed by people who work directly in the field under consultation with end-users or other relevant stakeholders, was the typical route to positive case study outcomes This level of input, though it may be found to complicate and lengthen a development process, may lead to a more robust policy or project in the long-term with considerable buy-in at all levels Evidence and Evaluation Partners were particularly asked about the use of evidence in the development of case studies as well as the extent of monitoring and evaluation Therefore, it is unsurprising that these factors were frequently identified in descriptions of the case studies and appeared to play prominent roles Despite being directly asked about this, it is possible that these factors would have emerged irrespective as they appeared to play significant roles in each case study The use of scientific evidence, in particular well-respected research evidence from international bodies such as the World Health Organisation, or academic institutions were common within case studies In addition, developing case studies on the back of national data demonstrating a problem such as obesity was also common These would add legitimacy at the outset to encourage development and implementation Independent, peer-reviewed and high quality research produced by what are considered to be unbiased institutions lends considerable weight to the process and encourages buy-in In the absence of such evidence for funding a pilot, much less a more widespread programme, would be considerably more risky Monitoring and evaluation were built into all of these case studies in differing forms and to measure different outcomes This may reflect the chosen area of focus – education – whereby monitoring and evaluation methods are expected and normalised A drawback for these methods is that frequently they are measuring specific outcomes rather than the long term, more obtuse outcomes For example, a nutritional programme can measure the percentage increase in eating healthier foods but the long term beneficial impact on physical health and well-being cannot be measured without a 38 considerable budget to undertake longitudinal research and commitment into the future In addition, extrapolating health outcomes based on one programme can be difficult when there are many other potentially influential factors Linking in with communication; publicising initiatives, policies, pilots and projects that work provide the wider health (and other sectors) community with evidence-models through which the agenda can be promoted in their own domain Sustainability Of great importance to ensure health is considered in educational policies and programmes, is the assurance that these processes are sustainable in the long-term These case studies frequently cited the ability to be sustained through several methods, principal among them being low-cost and curriculum-embedding To ensure that health does not become a luxury within educational systems when finances are strained or political upheaval alters priorities, keeping a project low-cost is essential However, being low-cost is not sufficient on its own, there must be enthusiasm to maintain the programme, project or policy and often ongoing evidence could facilitate this enthusiasm through demonstration of results To ensure a project is kept in place, roll-on projects to expand the number of people benefiting could be important In addition, updating the project to keep it interesting could also prove essential to keeping it fresh and keeping educators interested In a similar vein, frequently case studies demonstrated a ‘cascade’ effect; that is people beyond the original target audience were receiving benefits from the programme They were also enthused by the programme and an even wider circle was accessed This cascade effect, though it may be difficult to measure could be utilised as a tool to demonstrate the value-for-money that a project or policy was providing Although keeping things fresh and new, and maintaining enthusiasm should be key priorities, there was also a need to be mundane on some level Case studies were often successful (and low cost) by embedding the message in the existing curriculum Educators are already bombarded with extracurricular messages and add-on agendas to their workload, but by cleverly incorporating health messages into other subjects this could assist in decreasing the educators overall workload and making the new project and policy more acceptable It could also add another dimension to lessonplans and assist teachers in their roles In addition, by demonstrating the cross-subject links, children may also be taught to not perceive their worlds in silo-vision which has tainted so much modern policy-making Conclusion Health in all policies may require public health actors to step outside their own silo views and think about what health has come to mean The extension of ‘health’ beyond healthcare services to include the social determinants of health has meant a far more holistic and preventative method of tackling health inequalities and inequities through addressing root causes From this, it has also meant that what was traditionally in the domain of ‘health’ has spread its remit to a shared agenda with such other domains as transport, planning, education, environment, social welfare and social policy to name but a few Therefore, the answers perhaps lie within the health sector; what was it that made health reach out to these other sectors and take ownership? If the health sector has expanded its remit, perhaps other sectors would similarly like to expand their remits to achieve something larger than the sum of its parts However, acting as an advocate, public health actors cannot engage with every sector at the same time In targeting other sectors the easy-wins should not be the only focus, though it may be pragmatic to concentrate resources in these domains to start, the difficult areas and questions will need to be tackled to truly achieve a robust HiAP approach Evidence from Crossing Bridges suggests that using other sectors’ languages; getting to 39 know what is on their policy agendas at national, regional and local level can assist in the initial approach HiAP is often about the social determinants of health beyond health directly, and these social determinants are highly influential across multiple indicators external to health; for example, social and economic development Therefore, elements to include in the agenda that is required already exist Beyond this, public health will need to be flexible in its role, almost as an invisible assistant to the process and accept that wins must be shared, or perhaps to give headline credit to another sector In this, it must be identified what success would look like Many initiatives identified were not directly involved with the health sector, and some had no involvement with the health sector at all Are these still successes? And if so, when and how can success be measured? This report has identified “attribution challenges” (Public Health Agency of Canada, 2007); when evidence of a successful intervention cannot be evaluated in the short to medium term and causal relationships may not be reasonably established Long-term thinking, planning and monitoring may be on multiple sectors agendas, and this may be a route to encourage cross-sectoral dialogue Summary of identified methods for embedding health in all policies:  Political expediency: getting buy-in at the highest levels of policy formation may be ideal if it is not already present If not present, the importance of health to multiple policy agendas should be highlighted  Established regulations and relationships: Frameworks for inter-sectoral work are very important to facilitate this process, however relationship-building within these frameworks cannot be legislated for – this may be where higher ranking staff can play a role in ensuring cooperation Shared budgets and agendas facilitate flexibility and much successful intersectoral collaboration There is a need to move beyond rhetoric to systematic action  Communication: Learning to utilise other stakeholders’ knowledge and expertise may require engagement on their own territory using language they are familiar with in their own domains The complexities of other sectors and systems must be recognised and not shied away from The usefulness of new technologies for information dissemination, sharing ideas and attracting attention should not be under-estimated There may be many examples from the marketing and social media sectors that could be co-opted to facilitate this  Implementation: Implementation is needed at all levels and although an impetus may originate from the top-down or bottom-up, engagement and buy-in at all stakeholder levels is needed and useful for tapping in to expertise  Evidence and evaluation: Having an evidence-base for the policy, project or programme assists the strength of the argument for implementation and ongoing monitoring and evaluation not only ensures constant vigilance and a strong evidence-based, but also keeps the project in the spotlight  Sustainability: Keeping the costs low, reinvention and expansion, and ensuring the least disruption to staff assists the sustainability of programmes 40 References Dahlgren, G and Whitehead, M (1991) Policies and strategies to promote social equity in health Stockholm, Institute of Futures Studies Dahlgren, G and Whitehead, M (2006) European strategies for tackling social inequities in health: Levelling up Part Copenhagen, World Health Organisation Himmelman, A.T (2004) Collaboration for Change: Definitions, Decision-making Models, Roles and Collaboration Process Guide [accessed 15 August 2011 www.partneringintelligence.com/documents/5.02_Collaboration%20for%20a%20Change.doc] Jousilahti, P (2006) “The promotion of heart health: a vital investment for Europe” in Ståhl, T., Wismar, M., Ollila, E., Lahtinen, E and Leppo, K Health in All Policies: Prospects and potentials Ministry of Social Affairs and Health, Finland Norwegian Directorate of Health (October 2010) Health Promotion – achieving good health for all [accessed 15th August 2011 www.helsedirektoratet.no/vp/multimedia/archive/00313/IS1846E_Health_Pro_313559a.pdf] Public Health Agency of Canada (2007) Crossing Sectors – Experiences in Intersectoral Action, Public Policy and Health [accessed 12th August 2011 http://www.phac-aspc.gc.ca/publicat/2007/crosec/pdf/cro-sec_e.pdf] Public Health Agency of Canada and the World Health Organisation (2008) Health Equity through Intersectoral Action: An Analysis of 18 Country Case Studies [accessed 12th August 2011 http://www.who.int/social_determinants/resources/health_equity_isa_2008_en.pdf] Sihto, M., Ollila, E and Koivusalo, M (2006) “Principles and challenges of Health in All Policies” in Ståhl, T., Wismar, M., Ollila, E., Lahtinen, E and Leppo, K Health in All Policies: Prospects and potentials Ministry of Social Affairs and Health, Finland Ståhl, T., Wismar, M., Ollila, E., Lahtinen, E and Leppo, K (2006) Health in All Policies: Prospects and potentials Ministry of Social Affairs and Health, Finland Strand, M Brown, C Torgersen, T.P Giaever, O (2009) Setting the Political Agenda to Tackle Health Inequality in Norway WHO: Europe Suhrcke, M and de Paz Nieves, C (2011) The Impact of Health and Health Behaviours on Educational Outcomes in High-Income Countries: a review of the evidence Copenhagen, World Health Organisation Regional Office for Europe 41 Acknowledgements This report was compiled as part of the EuroHealthNet ‘Crossing Bridges’ project Sincere thanks are due to the staff of EuroHealthNet, in particular Claudia Marinetti, Yoline Kuipers, Caroline Costongs, Ingrid Stegeman, Liviana Zorzi and Clive Needle, as well as all contributing partners In addition, special thanks are due to Malcolm Ward, Public Health Wales Particular thanks for their valuable contributions go to: Ilona Renner Bundeszentrale für gesundheitliche Aufklärung Nationales Zentrum Frühe Hilfen Ostmerheimer Stre 220 51109 Kưln Dott ssa Daniela Galeone Director Ufficio II – Ministry of Health Dott.ssa Lucia De Noni National Coordinator of the project “Progetto Nazionale di Promozione dell’Attività Motoria” Dott.ssa Laura Valenari Dept Of Prevention, Local Health Trust, Ulss20 Verona Dott Massimo Mirandola Former Director, Office for International Health and Social Affairs, Veneto Region Dott Amleto Cattarin Current Director, Office for International Health and Social Affairs, Veneto Region Dott Fabrizio Guaita Director, Service for Health Education of Local Health Trust N° 13, Dolo-Mirano, Veneto Region Edit Bilics József Solymosy Tamás Joós László Borsos Tamás Bodor Krisztina Borsos-Lajos Barbara Koncz Tibor Demjén, Edina Bőti, Tone Poulsson Torgersen, Jane Hackett, An Taisce, Michael Maloney, Bord Bia Alina Sarnecka, Ministry of National Education, Warsaw Marta Widz, Warsaw City Mayor-Council Centre for Social Communication, Warsaw 42 ...Title: Report of the ? ?Health in All Policies’ focus area group on education & health Date: July 2011 Authors: Noëlle Cotter (Institute of Public Health in Ireland), Owen Metcalfe (Institute of Public... in the Faculty of Sport, the National Education Institute of the Republic of Slovenia Context: Health has been increasingly integrated into the education system since the active involvement of. .. already available since 2005 The Ministry of Education were courageous in following the advice of the health promotion sector in banning vending machines in schools The advice of the health promotion