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Championing Health Promoting Schools: A secondary school case study from Victoria, Australia

Nutrition Dietetics & Food
Epidemiology and Preventive Medicine Alfred Hospital

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Objective: School-based prevention interventions informed by the World Health Organization Health Promoting School (HPS) framework aim to improve the health and wellbeing of school-aged children, yet few studies describe factors influencing the successful implementation of this framework in secondary schools. This study sought to explore why and how secondary schools might implement the HPS framework and factors contributing to success. Design: Qualitative case study. Setting: A single secondary school in Victoria, Australia, purposefully selected due to local recognition of an HPS policy. Method: Data collection included semi-structured interviews, document retrieval, drawings and ethnographic observation. Data were analysed using framework analysis. Results: The school had elected to implement the policy as it aligned with its existing health and wellbeing policy framework and provided a flexible yet evidence-based framework to guide a whole-of-school approach to promoting health and wellbeing. Success was perceived to be dependent on selecting easier health priority areas to address initially, the allocation of a designated team to guide policy implementation and access to a skilled health promotion worker to assist implementation. Conclusion: Study findings highlight potential reasons why and how secondary schools might implement the HPS framework and factors contributing to success. Further research is warranted to enhance the transferability of these findings and explore the impact of the HPS framework in secondary schools.

health promoting schools
school health promotion
secondary school
whole-of-school approach

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10.1177/0017896920961121

Article Contents

Introduction, materials and methods, conclusion, limitations of the study and implications.

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Exploring learning outcomes of school-based health promotion—a multiple case study

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Monica Carlsson, Venka Simovska, Exploring learning outcomes of school-based health promotion—a multiple case study, Health Education Research , Volume 27, Issue 3, June 2012, Pages 437–447, https://doi.org/10.1093/her/cys011

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This paper discusses the findings of a multiple case study of a European health promotion project—Shape Up—a school-community approach to influencing determinants of a healthy and balanced growing up. The project sought to develop children’s capacity to critically explore and act to improve health-related conditions at school and in the community. The aim of the study is to explore learning outcomes, defined as changes in pupils’ action competence, of the Shape Up project. Further, the study addresses the interplay between the project’s methodology and contextual factors related to its implementation and its impact on learning outcomes. Case study research was conducted in five schools in five different countries. Data were generated through document analysis, interviews and observations. A cross-case analysis was conducted, inspired by the Context-Mechanism-Outcome analytical framework proposed by Pawson and Tilley (1997). Changes related to pupils’ knowledge, skills, visions, critical thinking and decision making, experience with taking action and a realization that they can change things stand out as essential for the pupils’ developing sense of action competence. Two different implementation forms of the project’s methodological approach were identified across the five cases, both conducive to changes in pupils’ action competence.

This paper discusses the learning outcomes, defined as changes in pupils’ action competence, in relation to health, resulting from a European health promotion project—the Shape Up project. Furthermore, it addresses how the interplay between the educational practices of the case schools and the teaching and learning approach used in the project methodology, the Investigation-Vision-Action-Change (IVAC) approach, may have influenced the learning outcomes.

The stated aims of the Shape Up project include addressing social determinants of healthy eating and physical activity and developing pupils’ action competence, i.e. their capacity to critically explore and act to improve health-related conditions, practices and choices. The project is based on the premise that a comprehensive approach, which includes school-community collaboration, pupils’ participation and an action-oriented teaching and learning model, is effective when it comes to both health and learning outcomes [ 1 ].

There is a growing societal interest in reducing childhood obesity and in health promotion and health education as a means to do so. As health promotion programs with shifting focus on various health issues are implemented in schools, a number of questions are raised [ 2 ]: are such programs effective in achieving the stated projects aims? If so, what components of the program make them effective and in what circumstances are they effective or not? A systematic review of studies on the effectiveness of school health promotion [ 3 ] concludes that programs that take into account contextual factors and emphasize multidimensional approaches are more likely to be effective in relation to health outcomes. Research that documents the effectiveness of school health promotion in relation to learning outcomes is, however, scarce.

At the same time, it has been repeatedly pointed out in the health promotion literature e.g. [ 4–6 ] that knowledge about contextual and program implementation factors in health promotion is as important as knowledge about whether a change took place or not. Against this background, this study uses the Context-Mechanism-Outcome analytical framework [ 7 ] to generate evidence about project outcomes that are sensitive to contextual differences and take into account project methodology and implementation factors. This framework has been employed in several case studies and evaluation studies within health promotion (e.g. [ 8 , 9 ]).

In the following, we begin with a description of the theoretical framework and the research aim and methods. We then continue with a discussion of the findings related to the contextual factors and program implementation in the Shape Up project as well as the findings related to pupils’ action competence. We conclude with a discussion of what characterizes the learning outcomes in the project and how the interplay between educational practices in the case schools and the IVAC approach, as implemented in the schools, may have influenced these outcomes.

Theoretical framework

As pointed out by Biesta [ 10 ], among others, the outcomes of education should be seen in close relation to methodological aspects and educational values. The concept of action competence and the IVAC approach are, together with a focus on pupil participation and school-community collaboration, the methodological framework and program theory in the Shape Up project [ 1 ], based on research and principals within the European Network of Health-Promoting Schools [ 11–14 ]. Embedded in critical education philosophy and its principles of emancipation and empowerment, education is seen as a qualification for participation in democracy and as a process that emancipates humans to be political subjects [ 15 ].

The IVAC approach is construed as a teaching and learning approach that is explicitly linked to the development of action competence. The different phases in IVAC are interconnected, although not necessarily in a linear way, and emphasize [ 13 ]:

(i) knowledge development through pupils’ own ‘Investigations’ of health issues,

(ii) development of commitment, motivation and engagement through pupils’ ‘Vision’ work,

(iii) development of pupils’ experiences with taking ‘Action’ and initiating health-promoting ‘Change’ .

Action competence in relation to health has been defined as ‘the ability to act, initiate and bring about positive changes with regard to health’ [ 13 ]. In this case study, the concept of action competence has been operationalized through the following mutually interwoven components:

(i) knowledge (multidimensional knowledge about health and health-promoting change, including ‘know-how’ aspects, i.e. skills),

(ii) commitment (motivation to become involved in initiating health-promoting change),

(iii) visions (to think behind and beyond health problems and think creatively about solution possibilities),

(iv) action experiences (real-life experiences with initiating and carrying out change).

The conceptualizations of action competence e.g. [ 16 , 17 ] demarcate action competence from notions embedded in behavior change theories. An action is always preceded by a conscious decision and what is done has to be aimed at solving the problems that are being addressed. In other words, an action is always intentional and goal oriented, while this is not necessarily the case in behavior change [ 18 ]. By describing action competence as an ability that is appropriated by the pupils, through their active participation in interaction and by stressing the importance of action experiences [ 14 ], a reference is made to constructivist and sociocultural understandings of learning.

Research aim, focus and questions

The aim of the study is to explore learning outcomes defined as changes in children’s action competence in relation to health and to uncover key mechanisms conducive to these changes in the interplay between the project’s methodology and contextual factors related to its implementation. The aim indicates that the case study is of an explorative nature and delineates it from case studies with evaluative purposes, which would focus on whether the project was ‘effective’ in the sense of whether it would be able to bring about certain outcomes efficiently.

The Context-Mechanism-Outcome (CMO) analytical framework [ 10 ] inspired the focus of the study. The CMO framework is based on realistic inquiry and is explorative; it aims at identifying, formulating testing and adjusting hypothesis about the mechanisms that can explain ‘what it is about a program that works’ [ 7 ]. The scope of this question can best be seen in relation to—and as opposed to—the traditional (and experimental trial design led) evidence question ‘what works’.

Inspired by the CMO framework the focus in the study is on:

(i) Educational practices in the five case schools—seen as crucial contextual factors in relation to the learning outcomes.

(ii) The interplay between the IVAC approach in the Shape Up project and the schools educational practices’—seen as part of the mechanisms for change.

(iii) The changes in children’s action competence operationalized in four main categories: Knowledge, Commitment, Visions and Action experience—seen as learning outcomes.

Change in relation to action competence is researched as a matter of social attribution, i.e. pupils, teachers and others ascribing certain meanings to change and not as a psychological reality that can be tested and measured [ 19 ]. The participants were in other words asked if and to what extent the project had led to a development of knowledge, commitment, visions and action experience and to describe the change in their own words.

The following research questions guided the study:

(i) What characterizes the learning outcomes defined as changes in pupil’s action competence in relation to health in the five case schools?

(ii) How did the interplay between educational practices in the case schools and the IVAC approach in the Shape Up project influence these learning outcomes?

Data generation

The five case schools were selected from a total 73 schools in 19 different European Union countries and cities that took part in the project between 2006 and2008, including at least one school from each of the three European regional clusters on the basis of which the project was organized. The five case schools are situated in Maastricht (the Netherlands—Northern), Mataro (Spain—Southern), Monza (Italy—Southern), Ballerup (Denmark—Northern) and Vienna (Austria—Central). Furthermore, the willingness to participate in the research among management and staff, and school size, was considered in the selection of schools: the size of the participating schools ranged from two small schools with 200 pupils (Maastricht and Monza), two medium-sized schools with 500–600 pupils (Mataro and Ballerup) and one large school with 1100 pupils (Vienna). The pupils involved in the cases are in lower secondary school (11–16 years).

The case studies were conducted by the following researchers from The Research Programme for Environmental and Health Education at Department of Education: Christina K. Albæk (Denmark and Spain), Pernille Dehn (Italy), Venka Simovska (Netherlands) and Monica Carlsson (Austria).

Qualitative data generation methods were employed, and the data sources included:

(i) project documents (project reports, descriptions of local contexts, coordinator/facilitator self-evaluation portfolios),

(ii) content on the project’s web portal ( http://www.shapeupeurope.net ),

(iii) observations made on two school visits—in the middle and at the end of the project (lasting 2–3 days per case),

(iv) interviews with local coordinators (LCs) and local facilitators (LFs) in each case ( N = 10),

(v) interviews with project participants: individual interviews with two teachers in each school ( N = 10) and group interviews with six pupils in each school ( N = 30).

The data generation was guided by a common data generation matrix and observation and interview guidelines and was conducted during the visits. The project documentation and the web material were printed and used as data records. Observation notes were taken immediately after each day spent at the school. The interviews, the meetings and the conversations were recorded and transcribed verbatim in English. In this paper, we draw most heavily on the interview, project documentation and portal data while observations provide secondary data from the single case reports.

Data were initially analyzed within single cases, after which a cross-case analysis was conducted. Both analyses were structured by the focus on ‘contextual’ factors, ‘mechanisms’ for change and ‘outcomes’, as outlined in the CMO analytical framework. In the initial single case-study analysis, we triangulated the data from the different sources (e.g. interviews with LF/LC were triangulated with the interviews with teachers and pupils; the web portal contents were triangulated with the project progress reports and self-evaluation portfolios; interview data was triangulated with document data).

In the cross-case analysis, we identified emerging themes and categories by combining inductive and theory-driven analytical approaches. We synthesized case data from the five cases, applying the principles of cross-case generalization as outlined by Simons [ 20 ]. The discussion of the findings followed an abductive analytical process [ 21 ], altering between observations and reflections related to the empirical findings on the one hand and the conceptual sources of inspiration in the theoretical framework on the other.

The traditional ethical principles of informed consent, confidentiality, non-deceptive practice and minimization of possible harm shaped the research.

Program implementation

Based on the data from project documents and interviews with LCs and LFs, Table I summarizes the specific activities that were undertaken in each school, which reflect the overall Shape Up topic—healthy eating and physical activity. As shown in the table, the school projects include activities decided on by pupils, e.g. establishing a playground and changing school food options (Schools A, D and E), as well as activities for pupils planned by adults, e.g. walks and outings in city parks (School B and C).

Case school projects.

In each city, a team consisting of a LF and a LC supported the schools during the project. The LCs and facilitators in Schools B, D and E were educational consultants from the municipality and school level, while in Schools A and C, they were from a welfare and a community participation organization, respectively.

The project documents show that in all the case schools, the project was developed and implemented by local partners (coordinators, facilitators, the school management and teachers) in collaboration with the international project partners. Hence, the project methodology was not based on a fixed static program implemented in all the different contexts but on several locally developed programs within a shared methodological framework. The project organization and communication were facilitated by an interactive web portal, a methodological guidebook and regular international project meetings and training activities (The organizational structure, methodological guidebook and evaluation report of the Shape Up project are available at http://www.shapeupeurope.net ).

The interplay between case schools educational practices and the IVAC approach

The cross-case analysis identified two main challenges related to the interplay between educational practices in the case schools and the IVAC approach in the Shape Up project. Firstly, the IVAC approach, based on a notion of learning through action experiences targeting action and change, was not embedded in the educational practices in any of the case schools. One of the schools—School D—had previous experience with the IVAC approach since the national curriculum guideline for health education employs the approach. However, the LF and the LC points out that many teachers are not familiar with this guideline. In the other schools, health themes were incorporated in the curriculum of core subjects such as home economics and physical education. Data from all five case schools demonstrate consistent accounts pointing to the challenges linked particularly with the change aspect of the IVAC approach, hereunder getting ‘very scared when you see the C [Change]’ (interview, LF/LC, School D), and finding that it is ‘a problem to get C [Change] at our school’ (interview LF/LC, School E).

Thus, the synthesis of data across the five case schools shows that the following two modifications of the IVAC approach can be identified.

(i) IVAC—a model including all four phases of the approach (Investigation, Vision, Action and Change), with emphasis on the investigation, vision and action phases and playing down the change phase. Three of the case schools (A, D and E) worked with this slightly modified model.

(ii) IV/AC—a model in which the action and change phases were separated from the investigation and vision phases. This model was employed in two schools (B and C).

Additionally, a tension between the project-oriented nature of the IVAC approach and subject-oriented educational practices in the case schools was identified. The demands placed on teachers to organize project-oriented teaching, while at the same time, ensuring the pupils achieve good grades in the different subjects (interview, LF, School A) and fulfilling curricular aims and documenting the results (interview, teacher, School D) can be seen as essential factors in shaping this tension. The tension appears to be a hindering factor in all case schools with regard to a realization of the full potential of the IVAC approach in supporting pupils’ development of action competence.

The five case schools are situated in different European regions and vary in size: the three case schools that applied the more comprehensive IVAC model comprised one small, one medium-sized and one large school, and representing both the central and northern regional clusters, while the two schools that applied the disconnected IVAC model comprised one small and one medium-sized school, both from the southern regional cluster. The findings give no indication that school size mattered in relation to the interplay between educational practices in the case schools and the IVAC approach in the Shape Up project. However, the findings suggest that sociocultural factors in the regions might have mattered: the case notes from the two schools in the southern region stress that the teachers seemed to find it necessary to protect the pupils from making decisions related to the action and change phases in the IVAC approach.

Changes in pupils’ action competence

Table II below synthesizes changes in relation to each component of action competence. As shown in the table, changes related to the knowledge component were reported at all case schools, while changes related to all four components of action competence were reported in three out of five case schools. In the following, we discuss each component separately.

Changes related to the four components of action competence across the five cases .

Changes in knowledge were articulated by teachers as pupils becoming ‘more conscious of health determinants’ (case notes, School C) or pupils developing ‘more extensive knowledge about healthy and unhealthy food and the importance of physical activity’ (case notes, School B). Similarly, pupils’ accounts point to knowledge of factors ‘about what lies behind health’ (interview, pupils, School D).

We have worked in Shape Up and know about health, so we just don’t stand up and say we want a cleaner school, we know what we are talking about (interview, pupils, School D).

They know what they want and how to talk e.g. to us as facilitators. In the democracy workshop as well—how to talk with politicians. They are really kind of self-confident (interview, LF/LC, School E).

In summary, the accounts on changes in relation to the knowledge component of action competence point out that both knowledge and skills development were seen as being conducive to the development of the pupils’ self-confidence and competence to take health-promoting action.

They want to leave their mark on things at school, they want to be involved and they are ready to take a responsibility (case study notes, School D).

You need to fight, with arguments, for what you want. Do not give up if it gets difficult. Keep on working (Interview, pupils, School A).

The extract points to pupils’ readiness to work hard for their ideas and visions and their experience that it pays off to persist in face of difficulties.

The data from the project documents show that in all five case schools pupils were encouraged to develop creative ideas for health-promoting changes. For example, at School A, the pupils developed visions for neighborhood playgrounds, at School B, visions related to food and body movement, at School C, ideas about ‘feeling good’, at School D, ideas for a healthy school tuck shop and at School E, visions for a healthy cafeteria. In the project documents from all five case schools, the work related to visions is described as closely related to the investigation phase in the school projects. In Schools A, D and E, the vision work also provided ideas to draw upon when selecting activities and deciding which actions to take.

You use your own brain—you don’t follow others without thinking [ … ]. They don’t allow themselves to be manipulated or anything. They have their ideas and they try to make them come true (interview teacher, School E). [ … ] they get the chance to sit at the table when the decisions are made and people listen to them … it’s fun how they have gained self-confidence [ … ] (interview teacher, School D).

Both quotes indicate that the school projects have allowed the pupils to become more autonomous and independent and that there has been a development in the pupils’ identities as political subjects that should be listened to and taken seriously.

Action experiences

The action experience component is identified in three of the five case schools (Schools A, D and E), construed both as experience in taking action, as a pupil preparedness to take action and as pupils’ realization that ‘we can change things’. For example, a teacher from School E emphasizes that the experience of interviewing people in the streets led to the pupils’ realization that they can do something, which was seen as crucial for that they later on went to the headmaster to tell him that they wanted a healthier school cafeteria (interview teacher, School E).

We changed what they have in the cafeteria [ . . .]! (interview, pupils, School E). [ … ] they tried hard but didn’t succeed (interview, teacher, School E).

[ … ] at first you think nothing can be changed and that you cannot go far in changing things and then you see that it is possible (interview, pupil, School A).

According to the accounts from these schools, the experience of taking action is crucial for the pupils’ developing realization that they can change things and for their preparedness to act. In contrast, the data from the two schools in which pupils mainly took part in activities that were planned by adults did not demonstrate that the pupils developed the action experience component of action competence.

In the findings, we have described what characterizes the learning outcomes in the five case schools. Through the study, our understanding of the content of the four components of action competence has been elucidated and elaborated. In comparison with previous conceptualizations of action competence [ 13 ] and previous studies (e.g. [ 11 , 18 ]), we operate with a slightly different content in relation to two of the components: we include ‘know-how’ aspects, i.e. discussion skills, in the knowledge component and consider these skills to be as important as ‘know-what’ aspects. Furthermore, we include critical thinking in the vision component, which in previous conceptualizations has been suggested as an independent component in action competence [ 18 ].

The findings from the cross-case analysis show that there is a link between pupils’ knowledge of health and their improved confidence to take part in discussions about health-promoting changes at school. In addition to knowledge, specific skills, including discussion skills, seem to be conducive to the development of pupils’ self-confidence. The experience of taking part in ‘critical decision making’, being heard and taken seriously, contributes to the pupils’ realization that they can change things, which seems to be as essential for the development of their action competence as the experience of taking action per se. This finding reflects the relevance of the educational philosophy that underpins the action competence concept and the IVAC approach—that action competence is developed through a process of raising critical consciousness. On the basis of these findings, we consider how critical thinking aspects can be better incorporated both in the concept of action competence and in the IVAC approach.

It is interesting to note that the pupils were eager to report that ‘we changed things!’ while adults assessed that ‘very little change took place’. The findings from our previous study on pupils’ perceptions on change in the x project demonstrate that pupils were meaningfully involved in bringing about health-promoting changes [ 22 ], so there is no indication that the difference in the perceptions of change is related to pupils’ disengagement with processes in the project. The difference in the perceptions of change might be related to the adults having higher expectations than the pupils. From a learning outcome point of view, we might consider if small-scale change can be just as conducive to the development of pupils’ action competence as large-scale change (and while being perceived as less challenging by the teachers). The question is not whether we ought to adjust the action experience-oriented IVAC approach in the direction of creating ‘as if’ learning situations: according to the findings, the experience of taking action is crucial to the pupils’ developing preparedness and confidence in their ability to change things. The value of the action and change aspects of the IVAC approach seems however not to be in the action and change in themselves but in the pupils’ perception of the action and change.

The CMO analytical framework has proved useful in identifying and exploring learning outcomes as well as outcome patterns developed through the interplay between the IVAC approach and the educational practices of the case schools. The study identified two outcome patterns (presented in Fig. 1 ).

Outcome patterns across cases in relation to learning outcomes in the Shape Up project.

The IVAC approach is based on a notion of learning through action experiences targeting action and change that was not embedded in the educational practices in the case schools. Consequently, two modifications of the IVAC approach were developed across case schools, each with it its own potential in relation to changes in pupil’s action competence:

(i) IVAC—a model including all four phases, developed in three of the case schools. This model seems to be conducive to changes related to all four components of action competence: pupils’ knowledge, commitment, visions and action experiences.

(ii) IV/AC—a model with disconnected investigation-vision and action-change phases, developed in two of the case schools. This model seems to be conducive mainly to changes in the first and second component of action competence: knowledge and visions.

The findings indicate that the interplay between the IVAC approach and the educational practices in the case schools is influenced not only by the teachers’ perceptions of action- and change-oriented teaching but also by their perceptions of the pupils and their abilities and their own roles in that regard. This is in line with the findings from a study of a school-based health promotion program pointing out that the teachers’ perceptions of the program, specifically its congruence with their own role and practice, are important in shaping their commitment to the program [ 23 ].

The case schools furthermore stressed the tension between the subject-oriented educational practices in the schools and the project-oriented nature of the IVAC approach in the Shape Up project. This is discussed as a potential hindering factor in a number of studies of school health promotion projects, hereunder a study of the Young Minds project [ 11 ] where one of the challenges reported by the teachers was ‘stepping back’ and ensuring more room for pupil participation on the one hand and helping pupils navigate through the subject matter on the other.

In summary, the study demonstrates that an action-oriented approach to school health promotion can be conducive to changes in pupils’ action competence. However, the interplay between project implementation and contextual factors substantially influences the scope of the outcomes. The interconnectedness of the phases in the IVAC approach is essential in order to support changes in relation to all four components of pupil’s action competence. This finding brings us back to the conceptualization of action competence, which emphasizes the importance of actions being intentional and aim oriented, which presupposes that pupils have been involved in decisions concerning what problems to address and what actions to take.

In the study, we draw cross-case conclusions from five different contexts with varying levels of complexity. Acknowledging concerns about generalization in case study research, we have formulated the conclusions in the tradition of qualitative empirical inquiry as suggested by Bassey [ 24 ], in which assertions and generalizations are constructed as interpretations with built-in uncertainty, ‘carrying the idea of possibility but not certainty’.

Further research is needed to explore the interplay between action- and change-oriented approaches in school-based health promotion projects and educational practices, as well as other contextual factors related to their implementation, especially in relation to how these approaches counteract existing social processes in schools. Also, research needs to focus on how the evidence-based turn in educational ideology, policy and governance, reflected in the quest to continually document the effects of education, influences value-based approaches in school health promotion where education is seen as a process of emancipation.

This work was supported by Research Programme for Environmental and Health Education, Department of Education, Aarhus University. The Shape Up project was supported by the European Commission Directorate General for Health and Consumer Affairs, Grant agreement (2005316).

Participating partner institutions in the project were: Danish School of Education, Aarhus University, Copenhagen, Denmark; P.A.U. Education, Barcelona, Spain; ABCittà, Milan, Italy; Schulen ans Netz, Bonn Germany and The University of Hull, Hull, United Kingdom.

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Educational Programs for the Promotion of Health at School: A Systematic Review

David pérez-jorge.

1 Department of Didactics and Educational Research, Faculty of Education, University of La Laguna, San Cristóbal de La Laguna, 38200 Santa Cruz de Tenerife, Spain; moc.liamg@9siulzelaznogardnajela (M.A.G.-L.); se.ude.llu@emijorcm (M.d.C.R.-J.)

María Alejandra González-Luis

María del carmen rodríguez-jiménez, eva ariño-mateo.

2 Department of Psychology, European University of Valencia, 46010 Valencia, Spain; [email protected]

Associated Data

Information and queries on the data used can be obtained from this article.

Context: Health promotion programs generate healthy changes in the educational community. However, not all of them meet the expected objectives due to multiple factors that affect their development, such as the teachers overload work, the lack of specific training, the lack of time to carry out health promotion activities, the lack of flexibility of the programs, and their non-inclusion in the training programs of the centers. Objective: To know the scope of the strategies and programs that promote healthy habits among students in compulsory educational stages. Data sources: a systematic review of articles in English, using the Web of Science (WOS), Medline, and PsycINFO databases.

1. Introduction

Health Promoting Schools (HpS) are resources for training, which are currently becoming a fundamental element for improving the comprehensive education of students, especially in the field of health. These schools favor the acquisition of knowledge and skills so that students are able to reflect and make decisions, in order to improve their health. These centers acquire a commitment to the development of training actions and to the implementation of programs for the promotion of healthy habits, creating a related awareness shared by all members of the educational community.

1.1. The Concept of Health

This work involves making a prior reflection on what is understood by health within the framework of the competencies that must be promoted from a school for its achievement. We start from the concept most agreed on and shared by the educational community, taking as a reference the definition from [ 1 ], which understands that health is the state of physical, mental, and social well-being of each individual and that it is a fundamental right of all citizens, without distinction of race, religion, political ideology, or economic or social conditions.

There are several approaches that have guided intervention in the field of health, as highlighted by [ 2 ]: (a) the preventive model, focused on early intervention; (b) the sanitary model, centered on the control of biophysical environmental conditions and; (c) the socio-medical model, focused on intervention in social and relational contexts. From our point of view, it is important to focus on the latter, since, as [ 3 ], this model relates the social, economic, and political context with the lifestyles of individuals. In this sense, it is considered essential to focus actions on health promotion, disease prevention, healing, and rehabilitation of people.

In this sense, [ 4 ] confirms that health forms a style and philosophy of life typical of each person and that it implies the promotion of autonomy that favors the configuration of one’s own personality. In this way, the individual is able to make their own decisions through a process of responsible reflection that helps them to adopt the habits and customs in solidarity with other citizens and with themselves, which has a positive impact on the enjoyment and improvement of their quality of life.

1.2. Health Promotion and Health Promoting Schools

In 1978, WHO, UNESCO, and UNICEF proposed various initiatives to introduce health promotion in schools. Years later, in 1986, the Ottawa Charter was drawn up, which recognized the importance of health education in achieving the wellbeing of all individuals [ 5 ]. Gradually, the promotion of health and healthy lifestyles has been promoted, in order to prevent diseases and improve people’s quality of life, which is why schools have taken a leading role in the promotion of health [ 6 ]. Reference [ 7 ] defines health promotion strategies in the school environment as a set of activities focused on improving the health of the entire educational community, and alludes to the need to influence the physical and social environments and policies of health promotion through the use of appropriate methodologies and school programs that promote their development. It is essential that the entire educational community be part of the health promotion process [ 8 ], therefore the need for health literacy arises, with the intention that people acquire knowledge and skills that allow them to promote health appropriately [ 9 ].

From the importance attributed to centers in the promotion of health, Health Promoting Schools (HpS) emerged, which oversee achieving social, economic, and environmental changes in the population in which they intervene. The essential function of HE is to develop the capacity of the entire educational community to achieve healthier lifestyles. These schools are in charge of carrying out activities that improve the health of the entire educational community, providing them with knowledge and habits for comprehensive care of people’s health. Reference [ 7 ] argues that the improvement of health states leads to an improvement in the academic results of the students.

Authors of [ 10 ] believe that it is essential to create policies that promote healthy lifestyles and prevent diseases, which should be promoted from educational centers as considered by the Ministry of Education, Culture, and Sports of the Government of Spain. Educational centers have direct access to students and the entire educational community, and therefore can directly influence the development of healthy habits and lifestyles. Educational centers are essential for the comprehensive development of students and the promotion of healthy lifestyles both physically, mentally, and socially.

As [ 7 ] underlines, HE aims to improve both the health of their students and their academic level through teaching and learning experiences and focused on actions related to well-being and healthy lifestyles. These actions are focused on elements that can affect health states, specifically referring to healthy eating, physical activity, emotional wellbeing, the consumption of drugs, tobacco, or alcohol, as well as the irresponsible use of Technology of Information and Communication (ICT), and the environment of the center.

1.3. Programs That Promote Health

An educational program is a set of activities that provides knowledge, skills, abilities, and competencies to students. Programs that promote health also have the objective of developing health in the educational community [ 11 ]. It is a teaching–learning process in which health is worked on and the quality of life of people is promoted, allowing critical thinking, affectivity, problem-solving, and social relationships develop [ 12 ]. According to [ 13 ], it is common for health risk behaviors to be seen in students, therefore, their prevention is essential through school programs that train and educate students. Reference [ 14 ] adds that educational centers are responsible for promoting health through programs, since through them healthy behaviors and habits are learned, thus avoiding risky behaviors. They state that health must be worked on throughout life, from childhood to adulthood, if a healthy culture and lifestyle is to be consolidated. The early approach and the consolidation of habits due to the influence effect are two of the reasons why educational centers are considered the most appropriate spaces to promote health [ 12 ].

The contribution of [ 15 ] affirms that for a health program to work, it is necessary that it be adapted to the context in which it is going to be implemented, moreover, they consider that this aspect is key if educational centers are to be a true HpS. The programs should not be implemented as something specific that is developed in certain circumstances, since health promotion must be part of the ideology and culture of the center, it must be a priority that must be addressed daily in the classroom, either as a specific subject [ 16 ] or in a transversal way [ 17 ]. Its value and relevance should prioritize its approach, giving time and opportunities for its internalization [ 16 ]. An example of the limited effects of specific actions in the field of health education is the study of [ 18 ], whose changes, despite being significant, were not maintained over time. The changes were observed with regard to healthy behaviors and knowledge about health, however, there were no changes in eating habits, nor in physical activity.

The main objective of this study is to know the scope of the strategies and programs that promote healthy habits among students in compulsory educational stages, using a systematic review methodology. We are unaware of the existence of previous systematic reviews, and this is a topic of great importance and relevance. For this reason, we consider it useful to identify the effectiveness of health promotion in HE.

Analyzing the existing theoretical framework, the research questions are:

What programs do health-promoting schools develop and promote?
Are educational programs effective in promoting healthy habits in students?
What are the difficulties and limitations for the development of programs that promote health in educational centers?

2. Materials and Methods

The programs that promote health in educational centers tend to focus on different areas, therefore, studies that address specific areas of health promotion and not only those that speak on health promotion in a generic way were accepted. In addition, all those who are part of the educational community (students, teachers, principals, families) were considered as participants. Studies on health promotion programs had to provide data on the benefits and/or limitations of the implementation of these programs, whether of a preventive or specific interventional nature. Therefore, at the beginning of this research, a series of criteria were established for the inclusion and exclusion of documents.

In this way, the criteria considered are shown in Table 1 :

Estimated inclusion and exclusion criteria.

2.1. Literature Review

A systematic review of the scientific literature focusing on health promotion programs in schools was carried out for this study. This type of study aims to know, through the systematization of the search for sources and studies, the state of research in relation to a topic or question of research [ 19 ] This study was developed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) declaration model for meta-analysis and systematic review studies [ 20 ]. The PRISMA statement guides the conceptual and methodological aspects considered during the development of systematic review studies [ 21 ]. It is a type of study that analyzes the scientific literature on a topic with the aim of constructing valid and objective conclusions [ 22 ]. This is not only a study that provides knowledge on how health promotion is carried out in schools, but also poses challenges that will open the way for new studies and research.

The search of the sources was carried out on the databases of the Web of Science (WOS), which compiles the most important articles in the educational field, in addition, the search was carried out on Medline and PsycINFO, as they collect studies most prominent in the field of health. The search for sources lasted approximately 4 weeks, beginning on 24 April 2021, and ending on 26 May of the same year.

The following terms were used to search the indicated databases: “Health promotion program” together with a combination of educational terms (“Early childhood education”, “Primary school”, “Secondary school”, “Compulsory education”, “obligatory education”, “primary education”, “secondary education”, “basic education”, “elementary school”, “early education” and “high school”). It should be noted that the search was limited to research articles in English.

2.2. Characteristics of the Included Studies

Initially, the search strategy used was too general and non-specific, obtaining too many documents that were not related to the objective of the work. This search strategy was used: (School OR “obligatory education”) AND “health promotion program”.

In order to refine and focus the search, the search terms were broken down and replaced with synonyms. On the one hand, “health promotion program” was maintained as it is the main focus of this search and, in turn, all other terms were selected and debugged. The terms “Early childhood education”, “Primary school” and “Secondary school” were alternated between. With these combinations of topics and Boolean operators, the search offered a number of suitable articles to start selection and subsequent analysis. However, it was considered necessary to add the synonyms of the primary topics. As a result, after determining the final selection and alternating different combinations with Boolean operators, the final search was established with: (“Early childhood education” OR “Primary school” OR “Secondary school” OR “Compulsory education” OR “obligatory education” OR “primary education” OR “secondary education” OR “basic education” OR “elementary school” OR “early education” OR “high school”) AND “health promotion program”.

2.3. Procedure

The eligibility assessment was carried out independently and standardized. To do this, we began by searching the three databases mentioned above and, using the Mendeley bibliographic manager, all documents that were duplicated were eliminated. After this, the inclusion criteria, indicated above, were applied, eliminating those documents that did not meet the requirements, for which it was necessary to read the titles and summaries of all the documents. Finally, a complete reading of the remaining documents was made to confirm that they met the objectives of the study.

To extract the necessary information from the reports, the Atlas.ti V. 7 (Qualitative analysis program, originated at the Berlin University of Technology, Berlin, Germany in a project called ATLAS, between 1989 and 1992. The acronym stands for Archiv für Technik, Lebenswelt und Alltagssprache) program was used, with which all the important information was selected and encoded to be accessed quickly and easily. The information extracted refers to the main characteristics of each health promotion program, the sample, and the country in which the program was carried out, as well as the educational level at which it was put into practice. Likewise, the study methodology (qualitative or quantitative) and the main results were extracted, in order to know its limitations and benefits.

3.1. Study Selection

We began by searching the databases, where 29 documents were identified in WOS, 26 articles in Medline, and 6 in PsycINFO. Therefore, the search resulted in a total of 61 documents. At this point, duplicates were eliminated using the Mendeley bibliometric manager, excluding a total of 22 articles. After this, the inclusion criteria were applied, eliminating 25 documents that were not written in the last 5 years (2016–2021) and 3 articles that were not in English. The titles and abstracts of the documents were then read, eliminating one that did not specifically deal with health promotion programs. Finally, there were a total of 10 documents that were read completely, after the complete reading, 3 that were not research studies on the application of programs were discarded. Finally, as can be seen in Figure 1 , the total number of documents to be analyzed was seven.

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Flow chart document.

3.2. Characteristics of the Included Studies

The seven articles selected for the review were research studies published in English and between the years 2016 and 2021, thus ensuring an analysis of the results on the application of programs for health promotion was updated. All the studies were international, carried out mainly in European countries (Ireland, Austria, Scotland, and Germany) and also in Australia, the United States of America, and Iran. According to the methodology used to approach the study, it was confirmed that two used qualitative methodology (28.57%; N = 2), another two quantitative (28.57%; N = 2), and three were mixed studies (42.85%; N = 3).

The evaluation instruments used were diverse, with more than one instrument in each of the studies, including: individual interviews (17.39%), questionnaires (43.47%), observations (4.34%), specific tests (skills and physical performance) (17.39%), focus groups (4.34%), electronic devices for routine and habit control (4.34%), and control scales (8.69%). As can be seen in Figure 2 , the most widely used were questionnaires, interviews, and tests.

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Evaluation instruments used in the different publications.

In most of the studies, the selected samples were students from educational centers; only one study focused solely on the views of teachers on the importance of health promotion in schools. This shows a significant weakness in the approaches of the interventions that are developed in schools. These are usually one-off actions carried out by health professionals in which teachers are hardly involved (e.g., vaccination campaigns, oral hygiene campaigns…).

Regarding the results, it should be noted that there are disparities, as some programs did meet the objectives that had been set while others did not meet expectations, and their application was not very effective. Likewise, three studies focused on the primary education stage (42.85%), three on compulsory secondary education (42.85%), and one on both stages (14.28%). As can be seen from the distribution of studies at the educational stage, these studies mainly focused on the stages of primary and secondary education. All the information can be seen in Table 2 , where the author or authors, year of publication, purpose, design, sample, evaluation instrument, type of program, and main results are also listed.

Primary outcomes of the reviewed articles.

3.3. Identification of Health Promotion Programs

Each of the selected studies worked on different types of programs to promote health in educational centers. The programs mainly focused on five areas of health promotion; as seen in Table 3 , these areas coincided with those proposed by [ 7 ].

Areas of health promotion.

The first study was conducted by [ 15 ] and focuses on the ACE program (Activity, Confidence, and Eating). This program promotes healthy eating, physical activity, and dental and mental health and was developed within the framework of the Schools for Health in Europe (SHE) network, and its objective was to improve the implementation of health promotion programs in educational centers. This program promoted the participation of families, students, and teachers through different activities, such as cooking courses, books, dietician support, etc.

The second study focused on the “Classes in Motion” program, evaluated by [ 27 ]. The author approached health through physical activity from an integrated approach, without modification of the curricular program. Prior to the implementation of the program, teachers were trained through specific workshops, to provide them with adequate knowledge about health and active teaching methodologies to improve the motivation and safety of their students.

The third study integrated an iron (Fe) deficiency control program, evaluated by [ 24 ]. It was a national health promotion program, focused on nutrition and increasing the consumption of Fe supplementation. The importance of this study lies in the fact that the prevalence of Fe deficiency anemia is very high at the global level and, specifically, in Iran affects 35% of the child population, 33% of non-pregnant women, and 40% of pregnant women. Thus, the program focused on a women’s center and was developed in three phases; weekly administration of Fe, monitoring and control, and nutritional information on foods rich in Fe.

The fourth program called the “A Stop Smoking in Schools Trial” (ASSIST) focused on tobacco prevention, as evaluated by [ 25 ], and was intended to extend, through the students themselves, information and knowledge on the prevention of tobacco use in all contexts, both school and family. The students received training from health experts and became a trainer and promoter of healthy behaviors and preventive smoking.

The fifth program called “Join the Healthy Boat”, evaluated by [ 26 ], focused on the promotion of non-sedentary habits and the responsible use and consumption of ICT. It focused on the importance of training teaching staff in physical activity, healthy diet, and active free time, as well as motivating families to take part in the project. Through the collaboration of families at home, they controlled exercises and activities for the development of healthy habits, especially relevant to preventing sedentary lifestyles in the pandemic period.

The sixth program, called “Active Teen Leaders Avoiding Screen-time” (ATLAS), studied by [ 27 ], aimed to improve the frequency of physical activity, reduce the intake of sugary drinks, and reduce the time and consumption of ICT. This program considered that these objectives were achievable by motivating, improving, and reinforcing the individual responsibility of each student in maintaining healthy habits. The intervention was based on the use of multiple resources (physical activity sessions, telephone app, and website for self-monitoring of physical activity).

The last program, called “Hopeful Minds”, evaluated by [ 28 ], focused on the mental well-being of students. It proposed the promotion of mental health through social and emotional learning experiences provided by teachers. The study plan was carried out in two phases. In the first, skills such as meditation or managing a journal for self-reflection were taught; in the second, exercise and improvement of these practices.

3.4. Effectiveness and Main Difficulties in the Development of Programs That Promote Health

The analysis of the results of the programs has confirmed that not all the programs were effective and not all of them achieved their expected results, as seen in Table 4 .

Effectiveness of health promotion programs.

In the study [ 15 ], focusing on the primary education stage, the main results showed that teachers considered that schools have a fundamental role in health promotion, they saw work on this issue as incompatible to due to their overload of daily work. For this reason, they suggested that the program should consider the study plan of the center so that it could be implemented without creating more workload for the teaching staff. In addition, due to the lack of training in health, teaching staff considered it very important to have professional support to promote health in an appropriate way. In addition, they stated that one of the most important points was to create and reinforce the bond between the school and family so that students acquire healthy habits.

The study [ 23 ] focused on primary school students between the ages of eight and nine. Even though volunteer teachers participated in the study, a fact that guaranteed greater commitment and motivation towards the program, the results were not as expected. Some positive changes were observed in motor skills that led to an improvement in coordination and spatial orientation skills, without other notable results regarding the acquisition of habits.

The results of the study carried out with women in secondary education [ 24 ] showed that the three main aspects of the program were not carried out efficiently, since the consumption of the pill due to Fe deficiency (food supplement) was very low and, among the consequences, was a lack of knowledge about health and, specifically, on nutrition, due to the fact that the training sessions were very scarce. Therefore, the program did not achieve its expected objectives.

The research [ 25 ], conducted in secondary education, highlighted the importance of peer support in relational activities and social interaction, with support partners benefiting the most. It must be kept in mind that the peer conversations did not penetrate as expected from the students. However, the program still achieved benefits for students, with improvements in self-esteem, communication skills, and group social cohesion.

The third and last study carried out in primary education [ 26 ], showed improvements in development and motivation towards physical activity or sports practice, however, this did not reduce the time dedicated to ICT consumption. In general terms, the program showed some changes, but it was not effective due to the scant participation and collaboration of families in controlling inappropriate habits.

The latest study [ 27 ], conducted in secondary education, showed the satisfaction of users with the activities of the program and the place where it was carried out. However, the program was very routine, causing a lack of motivation and interest in the proposed content. The motivation and support of the teachers were key to achieving the proposed objectives. The students became aware of the importance of daily exercise and sedentary behaviors were reduced, the consumption of sugary drinks was reduced, and their diet improved by introducing healthy food. From the empowerment of autonomy in decision-making, it was intended that the students become aware of their role in improving their health.

The study [ 28 ], in the stages of primary and secondary education on the effects on the emotional and mental health of students, showed that in the primary stage it was able to reduce anxiety and improve negative emotions, and an improvement in autonomy was evidenced in the management and control of emotions. However, in secondary education no improvements were observed in anxiety levels, although a resilient behavior of students with self-care habits and improved self-confidence was noted.

4. Discussion

The main purpose of this systematic review was to determine the effects of programs that promote health in educational centers. This review provides evidence that not all educational programs work, and, in many cases, the expected results are not achieved. However, those that work show positive effects regarding the development of skills, competencies, habits, well-being, etc. The articles reviewed were published between 2016 and 2021, and reflected the importance of educational centers in promoting healthy habits and lifestyles, considering the most effective context for their implementation. The number of studies carried out on programs that promote health has been scarce in recent years. That is why we believe that the development of training programs for the promotion of healthy habits should be promoted; in this sense, we believe that students should be taught to assume a proactive attitude towards the care and maintenance of healthy lifestyles. This is a commitment that requires the involvement of all social agents if we are to consolidate healthy and perpetual lifestyles. Even so, of the studies reviewed, it was found that: (a) the study samples varied and focused mainly on students, with studies focused on teachers and their training in health being especially scarce; (b) there is no clear and concise evaluation method to study health promotion in educational centers; and (c) the results obtained in the studies show variability in the effectiveness of the programs.

In general, not all programs work or generate behaviors that are compatible with the development of healthy habits in students and the rest of the educational community. The results of the systematic review carried out evidenced this fact. Only three of the seven programs obtained expected results, generating positive effects in students towards the development of healthy habits. From the programs presented above, results have been extracted that agree with the study carried out by [ 17 ], programs for the promotion of healthy habits have been found to take account of the school’s programming so that they can be carried out effectively, without overloading teachers. The planning and inclusion of health education in the school curriculum give it the continuous and integrated character that any knowledge requires to be acquired and integrated. Programs should tend to move away from isolated interventions in the form of ad hoc campaigns whose effect is insignificant (e.g., oral hygiene day, world sports day…).

Teachers demand the presence of experts to support the implementation of the programs, considering that they do not have sufficient qualifications for this task, and emphasize the importance of families being integrated into the school to achieve real change [ 15 ].

The participation of the entire educational community is essential for the success of these programs. As seen in the study [ 23 ], motivation of the teaching staff is not enough to achieve beneficial changes with the programs. Similarly, it was observed in the study [ 26 ], whose program did not work due to the low participation of families from home. Low family participation conditions the results [ 29 ]. When there is involvement and commitment on the part of families in the development of the programs, achievement of the results and goals of the program is favored [ 30 , 31 ].

Programs must be properly structured, focused on health promotion objectives, ensuring sufficient, adequate, and adapted training for students [ 24 ]. Specific or isolated interventions not adequately integrated into the training plan and educational programming of the centers do not guarantee the development of habits or the consolidation of self-care behaviors compatible with the health of the students [ 16 ]. It is essential that necessary time is dedicated to health promotion, to generate stable changes [ 18 ].

The findings of this study have highlighted the importance of having qualified and motivated teachers towards the promotion of health in schools, as well as having the spaces, resources, and materials for its promotion and consolidation [ 27 ]. Another study [ 30 ] corroborates the value of motivation and interest of the students towards the promotional health programs. The development of this type of program favored peer training, as well as the development of creative, critical, interpersonal thinking, and self-awareness skills that are fundamental for life [ 25 ]. Students learn in this way and by putting these skills into practice, to face health-related problems responsibly [ 31 ]. Peer learning has been established as a basic strategy for the promotion and consolidation of healthy habits and behaviors [ 25 ].

In the study [ 28 ], the relevance of training in the success of Health Education Programs was evidenced. Their experience properly developed and achieved optimal changes in the students, greater resilience, improved self-care, and decreased anxiety and negative thoughts were evidenced. Another study [ 29 ] valued the importance of the adequate development of health promotion programs, this type of action must be presented in the curricular framework of teaching and their actions must obey a strategic plan of actions focused on the improvement of the health of the students and the educational community. Specific or incomplete actions limiting the phase of action and change that must be carried out by the students and end up being actions without effect.

5. Conclusions

The main conclusions reached with this study are:

Education and health promotion programs in schools must link families with the educational center.
Improving the training of teachers in health matters is a requirement.
Health promotion is a social commitment that requires the participation of all its members.
Health education is not an exclusive commitment of schools, it must involve families and health professionals.
Health education must be a fundamental objective in the annual programming of schools.
Programs have to be well structured to work.
Peer training is beneficial and makes programs work.
The teacher must be a fundamental support point in the success of health promotion, they must lead the change by encouraging and motivating students towards the adoption of healthy habits.
An improvement in the qualification and training of teachers in the field of health is required.
Health promotion programs must be, above all, programs for the training of the entire educational community.

Author Contributions

Conceptualization, D.P.-J., M.A.G.-L. and E.A.-M.; methodology, D.P.-J. and M.d.C.R.-J.; formal analysis, D.P.-J. and M.A.G.-L.; investigation, D.P.-J., M.A.G.-L. and M.d.C.R.-J.; resources, D.P.-J. and E.A.-M.; writing—original draft preparation, D.P.-J. and M.d.C.R.-J.; writing—review, all authors; visualization, all authors; supervision, E.A.-M.; project administration, D.P.-J., M.A.G.-L. and E.A.-M. All authors have read and agreed to the published version of the manuscript.

This research was funded by the CajaCanarias Foundation and La Caixa Foundation Reference of the project IECVAD-COVID19.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of CEIBA (protocol code 2021-0462 approval date: 13 April 2021).

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

ORIGINAL RESEARCH article

What happens when a whole-school health promotion research trial ends a case study of the seher program in india.

1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
2 Center for Inquiry Into Mental Health, Pune, India
3 Centre for Adolescent Health, Murdoch Children’s Research Institute and Royal Children’s Hospital, Melbourne, VIC, Australia
4 Department of Paediatrics, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
5 Corstone India Foundation, Patna, India

Background: Health promotion interventions that are developed and evaluated by researchers and other external providers are at risk of not being sustained beyond the initial implementation period. When delivered by a lay school health worker, the SEHER study of a whole-school health promotion intervention in Bihar, India was found to be feasible, acceptable and effective in improving school climate and student health behaviors. The objective of this case study is to describe the decision-making processes, barriers, and enablers to continuing the SEHER intervention following its official closure.

Methods: For this exploratory qualitative case study, data were collected from four government-run secondary schools, two of which continued SEHER and two of which discontinued it after official closure. Thirteen school staff were interviewed, and 100 girls and boys (aged 15–18 years old) participated in eight focus groups discussing their experiences of the process of continuing the intervention (or discontinuing) following its official closure. Thematic analysis was conducted in NVivo 12 using grounded theory.

Results: No school sustained the intervention as originally delivered in the research trial. In two schools, the intervention was adapted by selecting sustainable components, whereas in two others it was discontinued altogether. We identified four interrelated themes that explained the complex decision-making process, barriers, and enablers related to program continuation: (1) understanding of the intervention philosophy among school staff; (2) school capabilities to continue with intervention activities; (3) school attitudes and motivation about implementing the intervention, and; (4) the education policy environment and governance structures. Suggestions for overcoming barriers included adequate resource allocation; training, supervision, and support from external providers and the Ministry of Education; and formal government approval to continue the intervention.

Conclusion: Sustaining this whole-school health promotion intervention in low-resource school settings in India depended on individual, school and government factors as well as external support. These findings suggest that health interventions will not necessarily become embedded in a school’s operations merely because they are designed as a whole-school approach or because they are effective. Research should identify the resources and processes required to balance planning for future sustainability while awaiting trial results about an intervention’s effectiveness.

Introduction

In recent decades, there has been growing interest in developing whole-school health promotion interventions by governments, external agencies, researchers and schools ( 1 – 3 ). A whole-school approach defines the entire school community as the unit of change and consists of an integrated set of planned, sequential, school-affiliated strategies, activities, and services intended to promote the optimal development of students on a physical, emotional, social, and educational level ( 2 , 3 ). These whole-school approaches recognize schools as learning environments that also support health and well-being through health promoting school policies and governance structures, the curriculum, the physical and social–emotional environment, links to families and the wider school community, and school-based health services ( 2 , 3 ). Whole-school health promotion interventions have been shown to improve a range of behaviors and health outcomes including increasing fruit and vegetable intake and physical activity, reducing tobacco use and bullying ( 4 , 5 ), and improving social, emotional, and behavioral adjustment ( 6 ). A key challenge for schools and education systems is ensuring that effective interventions continue to be sustained after their initial development and evaluation ( 7 ). Without this, the investment of time and resources during the start-up phase of research risks being wasted ( 8 ).

Although effective whole-school health promotion interventions are implemented in low- and middle-income countries (LMICs) ( 9 ), little data are available on the sustainability of these interventions once initial funding or support ceases ( 3 ). Definitions of “sustainability” vary, but it can be broadly defined as “the implementation of an effective initiative over a context-dependent timeframe leading to irreversible desirable system change” ( 10 ). In high-income countries (HICs), recent evidence shows that school capacity (e.g., resources, leadership), staff motivation and commitment, and the wider policy context influence the continuation of school-based health interventions ( 11 , 12 ). Also of importance is the ability of schools to adapt and embed those elements of an intervention that are fit for purpose within an individual school, but which are not necessarily consistent with the fixed elements or parameters of the original intervention (e.g., the requirements of a randomized controlled trial) ( 11 , 13 ). Contextual factors such as the degree of resourcing (e.g., staffing, access to funding), the nature of government involvement, and discrepancies between urban and rural schools are known to shape the success of initial intervention implementation. Not only can these contextual factors vary widely between HICs and LMICs but they are also likely to shape the sustainability of interventions in schools ( 3 , 14 ). Thus, the most critical factors that sustain whole-school health promotion interventions in HICs may not necessarily be applicable in LMICs or may operate in different ways.

In LMICs in particular, lack of funding, skills and prioritization by governments and schools can result in external providers such as NGOs, private businesses, or research teams initiating and delivering many health promotion interventions, rather than government or school staff ( 13 ). Although schools offer a suitable platform for the delivery of specific programs (e.g., supporting girls’ development, and improving nutrition), external partners may have less opportunity than education ministries to align and integrate an intervention to the wider activities within a school. Further, without an explicit focus on skill transfer from external providers to school staff, the sustainability of any intervention beyond the period of program funding is arguably even more challenging in LMICs than HICs, given larger class sizes and fewer opportunities for professional development ( 15 ). While these high-level factors have been reported across various LMICs, the complexity and heterogeneity between and within specific countries also need to be considered ( 2 – 4 ).

To this end, we sought to explore the experiences of schools following the implementation and evaluation of one of the largest whole-school health promotion intervention trials ever conducted in India, known as the SEHER (Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health) study ( 16 ). It was anticipated by those who developed and funded the intervention that following the cessation of the externally funded, four-year research project, interested schools may well be able to sustain the SEHER intervention. This was considered likely due to the trial’s positive effects on school climate and student health and health behaviors such as less bullying and fewer depressive symptoms, and because whole-school principles underpinned the development of the intervention which aimed to align and embed various health promotion actions into daily school practices ( 17 ). Further support for this perception came from the results of the pilot study and first follow-up assessment (8-month follow-up after baseline, Box 1), which showed improved school climate and adolescent health outcomes in the SEHER Mitra-led arm schools when compared with the schools in control and teacher-led intervention arms ( 16 , 17 ). The implementation of the SEHER intervention mirrored the reality of school health programs delivered in LMICs where there is typically high reliance on an external funder and implementing body ( 19 ). We saw this as a unique opportunity to shed light on the sustainability of the different elements of the SEHER intervention following the end of the trial.

Box 1: Overview of the SEHER trial ( 16 , 17 ).

Aim : To evaluate the effectiveness and cost-effectiveness of SEHER ( S trengthening E vidence base on sc H ool-based int E rventions for p R omoting adolescent health program), a whole-school multi-component health promotion intervention led by lay counselors or teachers (i.e., SEHER “Mitra” meaning friend ) in government-run secondary schools to promote school climate and thereby improve adolescent health outcomes.

Study setting and duration : 74 government-run secondary schools in the Nalanda district of Bihar, India, a poor district which has an adult literacy rate (64.4%), well below the national average (77.7%). Bihar is the third most populous state in India, home to more than 103 million people, of whom 22.5% are aged 10–19 years. Education is provided primarily by the state government’s Department of Education ( 18 ).

There were 25 schools in the SEHER Mitra (SM) arm, 24 schools in the teacher as SEHER Mitra (Teacher SM) arm, and 25 schools in the control arm.

Design : Cluster randomized controlled trial using repeated cross-sectional surveys (April 2015–February 2017). Three assessment points were at baseline (June 2015), 8 months after baseline (March 2016), and 17 months after baseline (December 2016).

Inclusion criteria : All students in grade 9 (13–15 years) and present on the day of assessment were eligible to participate in the study.

Total study participants : 13,035 at the baseline, 14,414 at the 8-month follow-up, and 15,232 at the 17-month follow-up.

Intervention : SEHER, a multi-component whole-school intervention was designed within the Health Promoting Schools (HPS) framework. The intervention’s conceptual framework emphasizes the importance of a positive school climate (i.e., supportive relationships between school community members, a sense of belonging to the school, a participative school environment, and student commitment to academic values).

The intervention identified four priority areas for action: promoting social skills among adolescents; engaging the school community in school-level decision-making processes; providing access to factual knowledge about health and risk behaviors to the school community; and enhancing problem-solving skills among adolescents.

The intervention strategies were organized at three levels: whole school, group, and individual. Whole-school level activities included establishing a School Health Promotion Committee; conducting regular awareness generation activities during a school assembly; organizing competitions; providing a platform for students to raise their concerns, complaints, and suggestions anonymously through a suggestion box; running a monthly wall-magazine; and, developing and implementing healthy school policies. Group-level activities included: forming and running classroom-based peer groups to address students’ concerns; a workshop for students on effective learning techniques; and a workshop for teachers on effective disciplinary practices in the school. Individual-level components included providing counseling services to students who self-referred or were referred by teachers for health complaints, social and emotional problems, and academic difficulties. This intervention was delivered either through a trained lay counselor, SEHER Mitra (SM, “friend”), or a trained teacher, called a teacher SEHER Mitra (Teacher SM).

Selection and training of SM/Teacher SM : The SMs were members of the local community who were over 18 years old, had completed at least a bachelor’s degree, and were fluent in the local language (Hindi). The Teacher SMs were nominated by the school principals, had a minimum of 5 years of teaching experience in secondary schools, had 15 or more years of service remaining, and did not teach the Adolescent Education Program curriculum (control intervention). The SMs and Teacher SMs underwent a week-long separate training, with an identical curriculum. This was followed by in-service training through separate monthly group meetings for SMs and Teacher SMs. Eight supervisors provided support and supervision to a combination of SMs and Teacher SMs through three planned visits per month.

Comparison intervention : The Bihar state government-run Adolescent Education Program (Tarang) was delivered in all three arms of the study. A trained teacher from each school ran classroom-based sessions on the process of growing up, establishing positive and responsible relationships, gender and sexuality, prevention of HIV and other sexually transmitted infections, and substance use. These topics were delivered during 16 h of sessions each academic year.

Primary outcome : School climate measured through the 28-item Beyond Blue School Climate Questionnaire.

Secondary outcomes : Depressive symptoms, frequency of bullying, attitude toward gender norms, knowledge of reproductive and sexual health, and violence (perpetration and victimization).

Main findings: Compared to the control group, the lay counselor-delivered intervention improved school climate, depression, bullying, attitude toward gender equity, violence victimization, and violence perpetration. These outcomes had larger effect sizes at the end of the 2nd follow-up than they did at the 1st follow-up. No intervention effect was found at either follow-up point for the teacher-delivered intervention. SM-led interventions cost US$3213 per school ($15.0 per student) and $1,390 per school ($7.4 per student) more than the existing Adolescent Education Program.

The objectives of this study were to describe the decision-making processes, barriers, and enablers around the continuation of the SEHER intervention in schools in Bihar, India following its official closure. Our wider goals were to consider the ways in which these barriers could be overcome.

The SEHER trial took place in the Nalanda district of Bihar, India between June 2015 and January 2017. Box 1 provides details of the four-year research study, which was conducted by Sangath, a not-for-profit organization in India. In short, the large randomized controlled trial took place in 74 of the 141 schools in the district, out of which one-third were allocated to the intervention group delivered by a lay counselor, named SEHER Mitra (SM; “Mitra” meaning “friend” in the Hindi language), one third to the intervention group delivered by a teacher, named Teacher-SEHER Mitra (Teacher SM), and the rest were assigned to a control group. The control group intervention was delivered in all three arms and consisted of a government-run Adolescent Education Program (AEP) delivered by a trained teacher. The SEHER intervention was designed and implemented in collaboration with the Department of Education, Government of Bihar. Following the final assessment of students in February 2017, Sangath formally closed the program at a joint meeting of all participating school principals, and program staff.

Study design and school sample

This study was an exploratory qualitative case study of four SEHER trial schools: one school from each of the two active trial arms where the intervention activities were continued and one school from each of the two trial arms where intervention activities were discontinued after the official closure of the trial. The case study method was chosen as it permits flexibility to explore program evaluation and development and testing of theory, as well as describing and interpreting research findings within the unit of analysis ( 20 ). The unit of analysis for this study was the continued and discontinued schools. Following the closure of the program, two schools intended to continue the intervention, one from each of the two active intervention arms of the study. Both these schools were included. Schools that discontinued the intervention were purposefully selected based on their willingness to participate in the study and their geographic proximity to the schools that continued.

Data collection

The study was conducted between September and December 2020 in the middle of the school year, which ran from April 2020 to March 2021 in Bihar. We conducted face-to-face semi-structured individual interviews with school staff and focus group discussions (FGDs) with randomly selected students in grades 9 and 10. In each selected school, the principal, the SM/Teacher SM (only in continued schools), the AEP teacher, and one purposively selected teacher, based on availability, were interviewed. Two FGDs were conducted within each school (one each with boys and girls in the co-educational schools). Schools were closed between March and August 2020 due to the COVID-19 pandemic; data collection took place when schools were formally open. For each school visit, researchers followed local government and school infection control procedures which included physical distancing, mask-wearing, and hand hygiene. The details of the sample are shown in Table 1 .

Table 1 . Details of interviews and focus group discussions by case study schools.

The staff interviews and FGD guides (see Box 2 for examples) covered the following topics: socio-cultural context and school governance structures; understanding of the intervention and its impact; roles of various school community members in the intervention activities; decision-making processes for continuing or discontinuing the intervention activities; and enablers and barriers considered in making the decision. In the continued schools, we also explored the current challenges, enablers, and opportunities in continuing with the intervention activities and possible ways to address the challenges. All interviews and FGDs were conducted in Hindi, the local language, by trained interviewers who were familiar with the SEHER intervention principles. Interviews lasted between 30 and 45 min, and FGDs lasted between 45 and 60 min. Each interview and FGD was audiotaped, transcribed verbatim, and translated into English. The interviewers’ notes were added to the transcripts.

Box 2: Example questions for school staff interviews and student focus group discussion.

Example staff questions:

• What were the reasons for the continuation/discontinuation of the SEHER intervention in your school after the official closure by the implementing organization?

• How did you decide on continuation/discontinuation?

• Who was involved in making this decision?

• What role did the principal play in this decision-making?

• Were the students involved in this process? If so, how?

• What kind of help did you receive from Sangath to continue the SEHER intervention in your school?

• What kind of help did you receive from the Department of Education to continue the SEHER intervention in your school?

• What factors posed a challenge to continuation? How did you overcome these challenges?

Example of student focus group vignette and questions:

Case vignette: Aman is a 16-year-old boy studying in grade 9. Aman belongs to a poor family. His parents are working as farm laborers. For the last couple of months, they have been asking Aman to stop going to school and help them with their work. Aman wants to study but also cannot say no to his parents. Aman is constantly worrying about this situation and does not know what to do.

• How likely do you think that could happen to anyone in your school?

• If Aman was your classmate, what would happen to him?

• Who could help Aman at your school? How?

• What activities are conducted in your school to help students like Aman?

• Who conducts these activities? How often do they occur?

• What topics or issues are discussed during these activities?

We used a grounded theory approach to thematic analysis ( 21 – 25 ). By using this approach, both deductive and inductive processes of qualitative data analysis could be combined. The themes covered in the interview and group discussion guides constituted an a-priori framework (i.e., deductive) for analysis, while the perceptions and views expressed by participants allowed the identification and progressive refinement of critical themes that were grounded within the data (i.e., inductive). The following steps were taken for the data analysis and interpretation. In the first stage, two authors (MR and SS) read and familiarized themselves with the data. In the second stage, these two authors selected a mix of interviews and group discussions across participant categories and applied open codes through categorizing parcels of data ( 25 ). Then, they reviewed the coded transcripts and based on the codes and original research questions, defined and collated codes into potential themes to develop a codebook. In the fourth stage, they independently applied the codebook to five randomly selected transcripts ( 25 ). Post-coding, a summative table was prepared to discuss and resolve all instances where consensus was not complete. At this stage, the cycles of inductive elaboration of themes from the data were followed by their deductive application to the data. The procedure ensured that data within each code were coherent and that there were clear distinctions between codes. This process also allowed the existing constructs of sustainability of school-based health interventions to be grouped and compared. The framework was revised in discussion with SMS until the three researchers were satisfied that it fully reflected the data. The revised codebook framework is shown in Supplementary file 1 .

Once refined, the codebook was applied to all transcripts, populating a matrix framework with verbatim and summarizing data from the transcripts using NVivo 12 software ( 26 ). Ongoing charting of each interview transcript took place during and after this process, comparing new data with earlier transcripts. This ensured that the resulting matrix provided a detailed and accessible overview of the data populating each theme and subtheme from every respondent. The matrix framework enabled exploration of the data by both theme, and respondent-type, which allowed us to develop a detailed description of each theme and subtheme, and to detect patterns and associations between and across themes in the data ( 25 ).

Ethical considerations

This study was approved by the Human Ethics Advisory Committee at The University of Melbourne, Australia (Ethics ID 2057035.1). Written informed consent was obtained from all adult participants. For participants under the age of 18, participant assent was obtained before each FGD, using parental opt-out consent due to the low-risk nature of the research.

Description of schools

In total, 2,502 students were enrolled in the four schools selected for the case study; three schools had less than 300 students while one school had 1,658 students. Three of the four schools were co-educational (58.8% boys) while the other was an all-girls school. In total, 36 teachers were employed across the four schools (Mean 10.5 ± 4.12; range: 6 to 16), with an additional 18 vacant teacher positions (Mean 4.5 ± 3.0; Range: 2–8).

Description of participants

Thirteen school staff were interviewed including four principals, seven teachers (including three AEP teachers), one SM, and one Teacher SM. Eight FGDs (5 with girls, 3 with boys) were conducted with 100 students (58 girls, 42 boys; aged 15–18) to discuss their experience of the intervention after its official closure.

Educational context

Both students and teachers described Bihar’s socio-cultural milieu and the relatively poor state of its education system. Teachers pointed out inadequate school infrastructure, including inadequate drinking water and sanitation facilities, insufficient and unsafe classrooms, understaffing in schools, delays in school infrastructure development activities due to bureaucratic procedures, and poor monitoring by government authorities.

Among the major barriers to completing 12 years of schooling, students pointed to poverty, family reluctance to educate girls in comparison to boys, gender discrimination at home, teacher absenteeism, and a poor sense of connection to the school. During the group discussion, a female student expressed:

“Students like us, living in villages, face multiple problems. Students drop out due to poor financial circumstances. Girls drop out of school because they are expected to assist in household chores and domestic work, while boys are expected to earn money to support the family. Boys are sent to work in factories, shops, and hotels in big cities. Many girls are forced to get married before they finish their education or asked to sit at home to support the education of their brothers. Many do not attend school during 'those' days [referring to menstruation] since there is no separate toilet for girls.”

School staff shared these understandings, with one of the interviewed teachers saying:

“Most of the students in our school are from lower castes and poor families. They are the first learning generation in their family. They [their families] do not understand the value of education and are indifferent to the education of their children, especially their girls, who they do not want to educate and [who] marry before they turn 18.”

Students and teachers noted the lack of physical infrastructure and resources in the schools, including insufficient classrooms and seating arrangements, the dilapidated condition of school buildings, and the lack of safe drinking water, and toilet and sanitation facilities. Teachers also commented on the lack of human resources, with one saying,

“All of the teachers are overburdened with academic and non-academic responsibilities. Our school has eight vacant teaching positions, and this is more or less the case throughout the entire state. Our school has about 80 students in each classroom…very difficult for a single teacher to manage crowded classrooms.”

Decision-making processes, barriers, and enablers to continuing the intervention after its official closure

No school sustained the intervention as originally delivered during the trial. Two schools ceased the intervention altogether and two schools adapted the intervention by selecting components that were perceived to be sustainable (e.g., no or low cost, could be incorporated within the existing school schedule). We identified four major themes related to the decision-making processes and implementation factors of whether a school continued or discontinued the intervention activities after its official closure (see Figure 1 ).

Figure 1 . Identified themes around the decision-making process, barriers, and enablers to implementation that led to continuation or discontinuation of the SEHER intervention in schools.

Understanding of the intervention philosophy among school staff

The degree to which school principals and teachers understood the SEHER intervention philosophy as a whole-school approach that had benefits for health as well as learning impacted its continuation. Teachers who were able to translate and generalize the SEHER principles into day-to-day activities of the whole school, as well as classroom-level pedagogy, were more likely to adapt the intervention, even under low resource conditions. One school, whose SM continued with intervention activities, adjusted internal resources to pay for the SM’s salary and continued with the no-cost and easy-to-implement intervention activities in order to sustain the engagement of students. The majority of these activities took place at the school and group level, including awareness generation activities during the assembly sessions, weekly classroom sessions, running a monthly wall-magazine and competitions, occasional workshops for students and teachers, and regular peer group activities. The principal of this school mentioned,

“Our team continued with the activities that were easy to implement and did not require additional resources. We reuse the wall magazines designed when the program was supported by Sangath. During the general assembly, we still discuss various topics, conduct yoga sessions, and occasionally present skits about health issues. Moreover, [SEHER Mitra] organizes competitions for students, but we have reduced the number of competitions and do not distribute prizes. Instead, we commend the winners during the assembly. Our students are still encouraged to submit problems and concerns through the speak-out box so that [SEHER Mitra] can get in touch with them. This program aims to boost students' participation in school and classroom activities…teaching staff who have understood this principle encourages students to participate through group activities.”

There was, however, a general lack of understanding among teachers and students about the principles of the intervention (Box 1). For example, there was no mention among the principals and teachers interviewed that the main goal of the intervention was to improve the physical, social, and emotional climate of the school. Among the four priority areas identified by the SEHER intervention for action (see Box 1), the principals and teachers only mentioned two as priorities, namely providing students with factual information about health risk behaviors, and helping them resolve personal problems. In the interview with AEP teachers, they noted some overlap in the content between SEHER and AEP but differences in delivery methods. One of the male AEP teachers from the intervention continued school reported,

“SEHER and Tarang (Adolescent Education Program) both instruct students about risk behaviors such as tobacco chewing and smoking, unprotected sexual practices, physical inactivity, and violence. I teach these issues in the classroom and the SEHER teaches these through an activity-based approach. One of our staff members is also trained to be a counselor for the students, so that teacher helps girls deal with their problems; when they have health concerns, they also tell me about them. Since an organization closed the SEHER program, the SEHER teacher and I work together to benefit students.”

When asked about the SEHER intervention’s objectives, focus group participants described some of the activities, such as wall magazines, assembly sessions, and the speak-out box in detail. One or two students in each FGD reported that the SEHER intervention’s primary objective is to help students solve personal and school-related problems. Notwithstanding this, they also described many instances in which school personnel did not respond to their concerns. A group of girls from one of the continued schools shared,

“Sometimes no matter how many times we write about a problem, it is not solved. Nobody takes any action related to our problem… We wrote about the students’ toilet. It is mostly locked and when it is opened it is not clean… We write about it but no action is taken.”

Interviewer: Did you discuss it with the teacher?

“Yes. We have told him about it…He said he would discuss it with the Principal…No action is taken so far.”

The SEHER intervention included a number of overarching components which were intended to support a positive school climate, including a school health promotion committee, health policies, and the involvement of parents (Box 1). Schools did not sustain these elements. Many teachers saw the opportunity to merge SEHER activities with those of other programs due to similarities in content or structure and had done some of this in the schools where the intervention activities continued. However, several challenges were identified around doing this, including the unwillingness of other program staff to be flexible in this way, which was compounded by a lack of time and other resource constraints, as well as a lack of endorsement from the Department of Education (See Policy environment and governance structure below). As one teacher from the intervention discontinued school explained,

“When Sangath was implementing the program, it was going on very well. Since the organization has left, there is no one to support and look after the program in our school… the program is not implemented anymore. Earlier a SEHER team member would visit our school once a month and plan activities with the [SEHER Mitra], and all teachers were informed about the activities in a monthly meeting. All of this is stopped now. The main reason is we do not have any resources to implement the program activities.”

School capabilities to continue with intervention activities

The capabilities of schools to continue with the intervention emerged as a strong theme. This included: the need for strong leadership; administrative and management support from the principal; the willingness of the teacher SM to continue with the intervention activities; the need for ongoing training and skill development for teachers to be able to continue the intervention activities; the need for dedicated time and resources (human, financial, technical and material); the need for data (e.g., around intervention benefits) to inform decision-making; and the presence of support networks between teachers within the school and between staff across other programs.

Conflicts of interest, leadership disputes, and disagreements among teachers characterized the decision-making process in schools that discontinued the program. In schools where some intervention activities were continued, teachers lauded the role of the principal as a leader and facilitator in creating a consensual plan of action to resolve conflicts and provide strategic guidance.

A few teachers mentioned that it was important to protect the process of decision-making from misunderstandings, conflicts, and interpersonal dynamics, and to share responsibilities based on collective interests to assure the long-term running of the intervention. Teachers mentioned that the decision-making process involved discussing clear roles for implementing intervention activities. For example, as one teacher from the discontinued schools explained,

“Teachers who are involved in the program activities should be exempted from other responsibilities from the school routine so that they can devote that time to implement program activities…the SEHER program activities require additional time and effort from the teachers. If exempted from other responsibilities, teachers can devote some time to plan and execute program activities on a regular basis and also think about and address the issues faced by the students. At the same time, other teachers need to support in implementing the program activities…we could not reach a consensus on this…the output was obvious.”

In schools where some intervention activities were continued, principals and intervention facilitators noted that they used the materials provided by Sangath and developed by students from earlier years such as wall magazines, posters, charts, and competitions. The intervention implementers also said that the initial training they received was beneficial. One of the intervention facilitators shared,

“Sangath trained us extremely well. We had very intensive weeklong training at the beginning of the program followed by monthly training sessions. Moreover, we were provided with written guidelines and supporting materials that enabled me to continue with activities such as general assembly sessions, the speak-out box, and the monthly wall magazines. I repurposed the wall magazines that we previously created due to limited resources. However, we would benefit from more resources.”

Yet in all schools, it was clear that should the intervention facilitator (the lay counselor or teacher) who is currently employed at the school and originally trained by Sangath leave the school, the intervention would be discontinued because fellow teachers did not have the training nor resources to continue the intervention activities. This was a key consideration in the decision-making process. One teacher from a discontinued school stressed the need to build skills and knowledge across teachers in the school,

“Other teachers should be trained to implement program activities… When all the teachers are trained in implementing the program activities then the program activities can be distributed among teachers and one teacher will not be overburdened with the delivery of the program activities.”

School attitudes and motivation about implementing the intervention

Teachers and students generally had positive opinions about the benefits of the intervention for students. They believed that the anticipated benefits for students (e.g., the program created conditions conducive to learning such as better attendance, better involvement of students in the classroom, and general improvement in interactions between students and teachers) was a factor that contributed to the decision to continue the intervention. Principals and teachers noted that economic and other hardships in the community and society affected students, and that they viewed the intervention as a way for schools to help students address personal problems and provide them with the necessary skills to be prepared for the future. One teacher from a continued school noted benefits to the socio-emotional environment of the school,

“Students in the rural area are naturally shy. This program encouraged them to be vocal about their needs… either through raising them in group meetings or the classroom or through a written chit dropped in the speak-out box… students became vocal. They would ask questions during the classroom sessions. They would discuss topics like child marriage, the dowry system, the education of girls, depression, and so on, in debates. There were activities on mental health… how to handle stress, how to manage anger, and relationships. This all helped the students.”

Another teacher from a continued school emphasized the benefits to student-teacher relationships,

“This program brought some sort of schedule and discipline among the students. We have seen improvement in the student-teacher relationship… Students started sharing a bond with the school and the teachers… the girls could approach me and other teachers with their problems. This is important to improve their health and overall life.”

Others mentioned improvements in school attendance and student engagement in learning. One noted “ We did observe an increase in students’ attendance during the SEHER program” while another said, “It helps in improving students’ engagement. ”

In the FGD, many students appreciated the information they received on a range of topics through SEHER activities and noted that these would otherwise not be discussed in school or in their communities. Additionally, they valued the opportunity to engage with fellow students and the intervention facilitator in fun activities that were not part of their regular studies but that helped them to gain knowledge and skills. Several students shared anecdotes about the facilitator helping them resolve personal problems while ensuring confidentiality. One of the girls from the intervention continued school shared,

“I was going through a personal problem. My parents wanted to stop my education and get me married. I was disturbed due to this fact and could not concentrate on anything. I did not know what to do so I went to SM sir. He patiently listened to my problem and assured me that nothing of that sort would happen. He asked me whether I would be okay if the principal talked to my parents, which I thought was an okay thing to do. My parents were called to the school. Our principal and SM sir discussed this issue with my father a couple of times and my parents agreed to continue my education and not to think about my marriage before I complete grade 12 education”.

Despite this, in all four schools, staff had mixed opinions about whether the intervention should be continued or not. Discontinuation was more likely when the principal did not drive decision-making, when teachers were unwilling to take on additional responsibilities, and when teachers had little interest or motivation to continue, which was influenced by ineffective or even conflictual interpersonal dynamics between teachers. In contrast, in all schools, relationships built on trust, authenticity, and cooperation were described as being important for the intervention to continue. As one teacher from the intervention continued school shared,

“[Teacher (SEHER Mitra)] and [teacher (Tarang)] work collaboratively, and the rest of the teachers in our school support them. Our school's principal is also cooperative and supports teachers in executing various activities…we work as a team.”

Thus, the level of commitment and dedication of key stakeholders (i.e., principal and SM/Teacher SM) and clear understanding, support, and motivation from all stakeholders about what was needed to continue the program were key considerations during the decision-making process.

Teacher attitudes extended beyond the specific aspects of the intervention to encompass their overarching values about teaching and learning, including the role of education in society. One teacher highlighted that the sustainability of the intervention partially lay in the school staff appreciating that school is not just a place for education, but also a place for building a foundation for a healthy and productive life,

“This decision [to continue the program] depends on what is the attitude and opinions of the teachers towards the program… Teachers in this school believe that the school is the place where students can be helped with their problems and [that it] influences the students’ future life. That is why we have continued [the program].”

Engagement with students in decision-making around plans for the intervention was apparent in schools that continued with the intervention, even if in a very perfunctory manner around sharing with students that the intervention was officially coming to an end. However, some teachers noted the extent to which students had been asked for their opinions about the intervention’s closure and suggested that this had contributed to the school’s decision-making process. One of the principals from a continued school shared,

“We informed the students of the closure of the program when the organization [Sangath] announced it. [Teacher] asked the girls how they felt about continuing the program activities in each classroom… that batch of girls is no longer in the school, (but) their opinions were important to the continuation of the program activities for upcoming batches.” (Principal of a continued school)

In contrast, students were not visible in decision-making in any way in the two discontinued schools. A teacher from a discontinued school mentioned,

“There was no need to consult with students. There are a few hundred students at the school, and we know that they may have different opinions. Some of the students kept asking why we weren't conducting the program activities. We told them that the organization had closed.” (Teacher from a discontinued school)

Education policy environment and governance structures

Teachers cited several barriers to intervention continuation that reflected aspects of policy and governance. These included the challenges of the top-down or vertical implementation of health and education programs in the state of Bihar; the challenge of “red tape” about complex bureaucratic processes around approval for funding; hierarchies and dynamics within the school and education system; the fragmented delivery of multiple health programs in schools; and lack of coordination between the Department of Education and the implementing agency (Sangath).

No school reported communicating with the Department of Education following the official cessation of the intervention, yet the need for a government directive to continue the intervention was frequently raised as a critical enabler of its continuation (See Overcoming barriers to continuation below). As one teacher from a discontinued school described,

“We cannot go against the Government's directives…We are ready to spend the school development fund for these programs but a proper directive should come from the Government. Right now, there is no such guideline…”

Another teacher from a continued school highlighted the need for government investment in teacher training and school capacity building,

“The Department should acknowledge the program and its importance. The Department can train the teachers and principals… give some freedom to the school principals to utilize the school funds.”

The uniqueness of each school and situation presented many challenges for the sustainability of the intervention after official closure and for the implementation process in the present - and future. Three common themes emerged as affecting sustainability at the school level: lack of a strategic plan by the organization to hand over the intervention to the Department of Education and schools, lack of preparation by the schools to continue implementation without help from the organization, and the schools’ actual implementation without any financial support or technical assistance. According to the interviewed teachers and principals, the organization did not work with the Department of Education to hand over the implementation and governance of the intervention nor did it work with participating schools to develop a roadmap for integrating the intervention activities into the daily school schedule in the absence of any resources. According to one of the principals from a discontinued school,

“In a joint meeting of all the schools, we were informed about the program closure. Because they have been clear about it since the start of the program, I cannot blame them. However, the organization could have collaborated with the Department of Education to continue the program activities with minimal assistance. In each school, more teachers could have been trained so that the schools could continue their implementation. At the end of the program, only one meeting was held to inform teachers that the program has closed… we would have liked the program team to help us continue the program at school.”

Overcoming barriers to continuation

Overall, participants described several opportunities that could help overcome a number of barriers to continuing the intervention, some of which have been already reported. These include: adequate allocation and accessibility of materials to deliver intervention activities; provision of training, support and supervision from both the Department of Education and Sangath; training of all teachers instead of a single teacher to facilitate team-based program delivery and ensure intervention sustainability through staffing changes; and rewards for teachers to deliver the intervention activities. As previously noted, formal communication from Sangath to the Department of Education was raised by a number of staff as a necessary strategy to help shift intervention responsibility and leadership from Sangath to the Department of Education.

One of the teachers described how government officials must relinquish their bureaucratic role and allow schools to handle funds and other resources. They also described the value of trained teachers sharing their learning with colleagues.

“For a school principal to make a school-level decision, there are a lot of procedural requirements. It is important that the Department of Education allows the school principals to make some decisions on their own regarding the school development funds to build school infrastructure and implement programs like SEHER and Tarang (AEP). At the same time, at the school level, teachers need to function as a unit and share information. When the program was implemented by Sangath, we had no access to the program guidelines and resource materials. If all the teachers had received copies, there would have been an increase in cooperation and engagement on their part.”

Prior to the SEHER program closure, principals and teachers suggested that team training at each school should have taken place to prepare the school as a unit to continue implementing the intervention, rather than burdening one teacher with intervention responsibilities. Beyond this, however, in the continuing schools, the SEHER Mitra also emphasized the need for ongoing coaching and supervision. For example, one noted,

“It is not always easy for me to provide solutions to the issues shared by the students. Previously, when Sangath was implementing the program, I was able to communicate with the supervisor regularly and resolve any issues that I had. Now, I do not know who to contact… the program is discontinued in almost all schools so I cannot contact my peers, nor can I contact anyone in the Department of Education…this is a pressing issue.”

According to one of the principals interviewed,

“To sustain the program, there will be a need for shared energy, commitment, and passion from all levels of leadership… the school principal needs to provide support and supervision to the teachers while the department officials need to provide funding and materials. Sangath should have coordinated with the Department of Education, which it did not. Nevertheless, they can initiate the discussion with the Department to continue program activities with minimal support and supervision… in essence, leadership and dedication at all levels are what is needed to move forward with such a program.”

In setting out to describe the decision-making processes, barriers, and enablers to continuing the SEHER intervention in Bihar, India following the completion of an effectiveness trial, we wished to explore the elements that promote sustainability of effective whole-school health promotion programs as little is known about the sustainability of programs that are developed and evaluated by external providers in LMICs after research funding ceases. We found that none of the four schools in this case study sustained the intervention as originally delivered. Two schools adapted the intervention by selecting components that were perceived as sustainable (e.g., no cost, activities could be incorporated within the existing school schedule), while two schools completely ceased the program. Overall, we identified four interrelated themes related to the sustainability of the intervention: (1) understanding of the intervention philosophy among school staff; (2) school capabilities to continue with intervention activities; (3) school attitudes and motivation about implementing the intervention; and (4) the education policy environment and governance structures .

These findings are broadly consistent with existing evidence from HICs. In their seminal review of the sustainability of 18 school-based health promotion interventions in HICs, Herlitz et al. ( 11 ) found that no intervention was sustained in its entirety (e.g., some intervention components were continued while others were not). Indeed, overall costs, ease of implementation of intervention activities, and adaptation of the intervention to suit a school’s day-to-day operations were found to be part of the sustainability process ( 2 , 3 , 11 – 13 ). The importance of school capacity (e.g., resources, leadership support, and trained staff), staff motivation and commitment (e.g., staff confidence, perception of intervention benefit to both health and education, whole-school engagement) were also important and align with the themes we identified ( 3 , 11 ). While the review by Herlitz et al. ( 11 ) identified the role of the wider health policy environment, this case study identified the critical role of the Department of Education in providing the necessary conditions (i.e., endorsement, funding allocation, communication with external providers and schools, leadership, student-teacher ratio) for sustainability to occur. The importance of national and sub-national governance structures, led by the Ministry/Department of Education is increasingly being recognized as critical to the sustainability and scalability of these programs ( 2 , 3 ).

We found no apparent relationship between those schools in the trial arm where the SEHER intervention was found to be effective (i.e., SM active intervention arm) or ineffective (i.e., Teacher SM active intervention arm) and whether they continued the intervention. This is also consistent with the Herlitz et al. ( 11 ) review, which showed that while the effectiveness of a school-based health promotion intervention was not associated with its sustainability, the perception of benefit was. This was also the case in this study, where school staff and students perceived the intervention to be effective and valuable for many outcomes, despite several of these not specifically being measured (e.g., school attendance) and only the SM arm being effective relative to the AEP control arm in the original SEHER trial ( 16 ). This perception appeared to drive teacher motivation and commitment to continue with the intervention, even in these low-resource conditions, in which limitations around relying on teacher motivation were also apparent.

The ability of school staff to identify opportunities to integrate intervention activities with existing curricula or other health programs already being delivered was critical to sustainability. Yet, this case study showed that schools “defaulted” to a programmatic approach when deciding whether to continue the intervention. That is, schools perceived the “program” to be the activities and curricula-based elements designed to improve health knowledge (usually about a single problem or health topic), including one-on-one counseling of students, rather than continuing more structural (e.g., school policies, committees), pedagogical (e.g., how teachers teach and engage with students and student learning, rather than what they teach) or environmental elements (e.g., cleanliness of female toilets, access to the library, engaging in respectful conversations, including students in decision-making or listening to their concerns, providing a safe place for students). In continued schools, the more overtly programmatic elements were continued, while in the discontinued schools, these were the same elements that were the focus of discussion when determining whether the intervention could be continued. This is particularly noteworthy given that the SEHER trial was found to be effective in its aims to improve the school climate (i.e., supportive relationships between school community members, a sense of belonging to the school, a participative school environment, and student commitment to academic values) rather than having a more narrow focus on only improving health knowledge or outcomes. This is in marked contrast to the control arm of the trial, the AEP, that took a programmatic approach with a fixed curricla. One benefit of a programmatic approach is that it can be more readily outsourced to others (i.e., community-based partners) than when it is integrated into teacher roles. Yet if an effective whole-school intervention (such as SEHER) is reduced to its programmatic elements in the absence of connection to its wider intervention ethos, then it risks neglecting the essence of the program and potentially, the mechanisms driving change. Indeed in the SEHER intervention, mediation analyses showed that a nurturing school environment (supportive and engaged relationships with teachers and peers, a sense of belonging, and active participation in school climate) was the mechanism through which lower rates of depressive symptoms, experiences of bullying, and perpetration of violence occurred at follow-up ( 27 ). The value of school social–emotional environments and supportive relationships within schools for mental health (the focus of the SEHER interventions) was emphasized in a recent systematic review of longitudinal studies that found that over time, higher levels of school connectedness were associated with lower levels of depressive and anxiety symptoms in secondary school students ( 7 ). These findings are also consistent with previous research demonstrating that whole-school elements that change school climate have “flow-on” effects for health (e.g., reducing substance use) that affect later cohorts of students ( 28 ). This suggests that non-programmatic elements (e.g., pedagogical aspects, policy requirements, teacher training, and supervision) can lead to wider benefits for health in ways that may well be more efficient than what can be achieved through specific health programs.

This tendency to adopt a programmatic approach may be explained by several factors. Some teachers may not have had the knowledge, skills, and attitudes around whole-school approaches and be insufficiently orientated to the links between health and education or approaches that enhance school climate. Further, it may be that teachers did not feel that they had the capacity or permission (at the school leadership or school policy level) to effect change, whether inside or outside of the classroom. There may also have been the assumption from the external provider that both the activities and ethos of the SEHER intervention would permeate through the school community following the program closure by virtue of being a “whole-school” approach. The health sector, including those involved in research, has traditionally viewed schools as a platform for delivering health promoting interventions through the curriculum (e.g., sexual and reproductive health), programs (e.g., school meals), or health services (e.g., immunization) ( 29 ). Even when interventions are framed as multi-level or “whole-school,” they are not typically designed in a way that recognizes that schools are complex, adaptive systems that constantly evolve to the needs and priorities of students and the school community and in response to the input conditions (e.g., resourcing, attitudes) ( 30 ). Some teachers in this study appreciated and made efforts to promote the more relational aspects of the intervention (e.g., respectful engagement, active listening, engaging with and responding to individual student concerns). While these elements could very efficiently be provided by teachers, regardless of the continuation or not of the SEHER intervention, most teachers did not perceive these elements as constituting the intervention.

Together, these findings indicate the importance of governance structures for the sustained implementation of programs ( 13 ). Investment and leadership from the Department of Education in Bihar was fundamental, and our findings also highlight that the governance role of external providers including researchers was also critical ( 12 ). SEHER was originally designed and implemented as a randomised controlled trial of a health intervention within a research context and supported by funding external to the school system. The findings suggest that planning for sustainability within the design of an intervention and in partnership with key stakeholders is important or crucial. Ensuring appropriate handover of governance from the external research provider to the Department of Education appears a critical aspect of gaining Department of Education buy-in, which our findings showed was also important for individual schools. This will include explicit and ongoing training and support for schools, as the programmatic elements of the program will not automatically generalize to other areas of school life, without which the knowledge and skills will disproportionately fall to a small number of motivated teachers and threaten sustainability. Funding to support the non-teacher staff roles (e.g., critical friend, SM) who can champion the program and engage in a distributed model of leadership appears critical. In this study, facilitators outside of the school were important for building the motivation of the SM, equipping them with updated resources, and providing mentorship that connected the SM to others in the school. This is potentially reflected in the results of the original SEHER trial which showed that the intervention was not effective in the teacher as SM arm, but was effective in the SM arm where the SM was able to incorporate the wider elements of a whole-school approach. However, the challenge faced by any robust trial—where it cannot be assumed in advance what the findings will be—is that typically, the research budget is spent on running the trial ( 31 ). There is a necessary hiatus between completing the trial and having results available to share with stakeholders who may be responsible for funding the ongoing intervention. In that interregnum, even when there is interest in sustaining the intervention should it be found to be effective, momentum and interest risks being lost by individual schools when staff move on and other priorities emerge. This challenge may remain even if researchers manage to obtain funding to support ongoing implementation.

To shift this perspective, there is a growing appreciation of the wider opportunities for health promotion through whole-school systems approaches, such as WHO and UNESCO’s Global Standards for Health Promoting Schools and Systems ( 31 ) and its implementation guidance ( 3 , 32 ). This approach aims to integrate health promotion into the daily practices or culture of a school, reinforcing knowledge and skills outside the classroom, and engaging school staff, parents, and local communities (i.e., fundamentally appreciating links between health and education). This framework aims to aid the progressive sustainable implementation of health promotion in schools by addressing the governance required by governments and school leaders, including the need for health and education sector collaboration, by engaging students and developing collaborative networks within schools, reviewing and integrating existing programs, building teacher capacity and monitoring and evaluation. The findings of this case study reinforce this approach, especially the importance of authorizing environments and building teacher capacity (e.g., training, and supervision). Additionally, these results imply that funding agencies and researchers need to invest in developing innovative evaluation frameworks to establish implementation science indicators including maintenance, transferability, and sustainability for such interventions within project cycles.

This case study provides the first empirical evidence of how the desire to sustain a whole-school health promotion intervention and the continuation of intervention activities in low-resource setting schools in India depended on individual, school-level, and government-level factors, and the degree of support provided by the external provider of the program after its formal closure. Notwithstanding the importance of understanding a rural Indian context in order to address these issues, the barriers and enablers identified in this study are similar to those found in other studies, including in HICs [(e.g., 11 , 12 , 33 )]. It addresses an important gap in implementation research as a dearth of studies have examined the sustainability of whole-school health promotion programs, especially in LMICs. As a result of the ongoing COVID-19 pandemic restrictions, data were obtained from a limited number of schools via convenience sampling. While we included the important stakeholders in a school community, including students, these findings require cautious consideration when transferring to other settings, even if notionally similar. We adopted a multi-stage and iterative process of data interpretation, however, there is scope for observer bias due to the nature of qualitative data, particularly as Sangath staff conducted the interviews. However, participants’ critical comments about Sangath’s role in ongoing implementation suggest that this is unlikely to have been a major concern. Due to limited resources and constraints because of the COVID-19 pandemic, we could not interview representatives from the Department of Education and SEHER intervention staff. Their opinions and positions would have further enriched our findings.

Many school-based health promotion programs are developed and evaluated by external providers which present challenges to sustainability when initial funding and support ceases. Four key sustainability constructs emerged. Firstly, it is critical to collectively develop an understanding of the educational environment and socio-political context during the intervention co-creation and implementation stages. Effective health programs will not necessarily become embedded within the day-to-day operations of a school simply because they are designed to take a “whole-school” approach. Rather, it is necessary for researchers to plan for program sustainability beyond the initial trial period early in the study design and in consultation with school-level and government-level stakeholders, and potential funders. Arguably, this is particularly important in settings where there is reliance on external providers to deliver interventions. External providers must look beyond the resourcing required to continue specific (especially didactic) components of the program itself and also consider the required governance structures, partnerships, and training. This process should be balanced with the possibility that the intervention should not be sustained if trial results indicate it is ineffective or that the process of sustainability necessitates a substantial deviation from a manualized program. Secondly, it is crucial to invest in the development of committed leadership and motivation among school staff, as this can facilitate the integration of the intervention into school policies and day-to-day functions. Assisting school staff to recognize the importance of student engagement is part of this task. Thirdly, seamless integration of intervention activities into school practices and support from networks both in and outside the school requires investment in translating the program’s philosophy and underpinning principles across the school community throughout the project cycle. Finally, school administration and teachers’ commitment and support, observations of positive impact on students’ behavior and well-being, and confidence in delivering health promotion and their belief in its value may facilitate or prohibit schools from sustaining health interventions. The identification of resources and processes, including those that support convergence between health and education sectors, is required when considering future sustainability (e.g., phased program closure, identifying roles of different partners, decisions regarding resource and funding allocation, realist evaluations). How this is achieved in the context of uncertain benefit of interventions at the time of their design, implementation and evaluation is an important avenue for future research.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by this study was approved by the Human Ethics Advisory Committee at The University of Melbourne, Australia (Ethics ID 2057035.1). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained for all adult participants. For participants under the age of 18, participant assent was obtained, using parental opt-out consent due to the low-risk nature of the research.

Author contributions

SMS, MR, and SS contributed to the study design and implementation, analysis of results, and writing of the manuscript. On the ground, AS collected data, performed transcriptions, and translated documents. The first draft of the manuscript was prepared by SS and MR, and all authors reviewed it. All authors contributed to the article and approved the submitted version.

The India School Engagement Grant (2020) at The University of Melbourne supported the primary data collection for this study through a grant to SMS. MR is supported through the Centre of Research Excellence: Driving Global Investment in Adolescent Health funded by the NHMRC (grant no.: APP1171981).

Acknowledgments

The authors would like to thank Phanendra Sahay, Prachi Khandeparkar, and Bernadette Pereira for supporting the data collection and transcription process. The authors also thank all the students, teachers, and staff of the four secondary schools who participated in the study in Bihar.

Conflict of interest

MR and SMS have received consultancy funds from WHO and UNESCO to produce a body of work related to the “Health Promoting Schools” initiative. SS and AS were employed to implement the SEHER project by Sangath, a not-for-profit organization based in Goa, India.

Publisher’s note

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Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1112710/full#supplementary-material

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Keywords: whole-school intervention, mental health, adolescents, sustainability, schools, education

Citation: Shinde S, Raniti M, Sharma A and Sawyer SM (2023) What happens when a whole-school health promotion research trial ends? a case study of the SEHER program in India. Front. Psychiatry . 14:1112710. doi: 10.3389/fpsyt.2023.1112710

Received: 30 November 2022; Accepted: 26 May 2023; Published: 23 June 2023.

Reviewed by:

Copyright © 2023 Shinde, Raniti, Sharma and Sawyer. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Susan M. Sawyer, [email protected]

† These authors have contributed equally to this work

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Case Studies in Global School Health Promotion: From Research to Practice 2009th Edition, Kindle Edition

A growing body of research identifies strong links between children’s health, social and educational outcomes; it also notes the reciprocal benefits of access to quality education on individual and family health status. In response to these findings, the World Health Organization developed the concept of the Health-Promoting School (HPS), a living catalyst for healthy lives, and for positive changes that students can take home and into the community. Case Studies in Global School Health Promotion provides readers with a theoretical and research base needed to understand the methods used in communities all over the world to put this captivating concept in place.

Case examples from over two dozen countries (representing urban and rural areas in developing and developed nations) outline the strategies taken to implement HPS programs in individual schools, municipalities, and nations. For each program, case study authors explain the problems they tackled, their motivation and supports to respond creatively; and the barriers they faced. In the cases, authors describe the capacities and infrastructure they created and mechanisms for cooperation; as well as the personnel, financial, and time requirements involved. Case studies were drawn from the following regions:

The Americas
Eastern Mediterranean
South and Southeast Asia
Western Pacific.

Case Studies in Global School Health Promotion offers a world of insights, ideas, and guidance to those addressing social determinants of health at this formative stage, including: education and health policy makers; professionals and administrators; and researchers in national governments, universities, local schools, community, non-governmental organizations and civil society. The material provides interesting and useful information to those dedicated to these issues within WHO, FRESH Partners and other United Nations agencies. It is also an instructive text for graduate students in public health, education, allied health professions and social sciences.

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"Using a case-based approach, this book describes the application of the health-promoting school (HPS) model to improve child health outcomes globally. … The audience is primarily graduate students in public health, education, allied health professions, and social sciences. A secondary audience is educators, policy makers, professionals and administrators in national governments, universities, nongovernmental agencies, schools, and civil society. The use of the case-based application is effective in covering the conceptual framework of HPS." (Carole A. Kenner, Doody’s Review Service, July, 2009)

From the Back Cover

Case Studies in Global School Health Promotion

Cheryl Vince Whitman and Carmen Aldinger

Western Pacific

Case Studies in Global School Health Promotion offers a world of insights, ideas, and guidance to those addressing social determinants of health at this formative stage, including: education and health policy makers; professionals and administrators; and researchers in national governments, universities, local schools, community, non-governmental organizations and civil society. The material provides interesting and useful information to those dedicated to these issues within WHO, FRESH (Focus Resources on Effective School Health) Partners and other United Nations agencies. It is also an instructive text for graduate students in public health, education, allied health professions and social sciences.

About the Author

Cheryl Vince Whitman is a Senior Vice President and Division Director of the Health & Human Development Programs at Education Development Center.

Carmen Aldinger is a Project Director at Education Development Center (Newton, MA), where she manages the WHO Collaborating Center to Promote Health through Schools and Communities.

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Chapter: chapter 6 - case studies: health promotion programs.

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53 6.1 Introduction The case studies and analyses presented in this chapter introduce primary source employee demographic and wellness program participation data collected from five major metropolitan transit agencies: â¢ The Indianapolis Public Transportation Corporation (IndyGo), in Indianapolis, Indiana; â¢ The Regional Transit Service (RTS), in Rochester, New York; â¢ The Transit Authority of River City (TARC), in Louisville, Kentucky; â¢ The Des Moines Area Regional Transit Authority (DART), in Des Moines, Iowa; and â¢ The Los Angeles Metropolitan Transit Agency (LA Metro), in Los Angeles, California. The analysis involved a review of descriptive literature publicly available from agencies or provided to the project team by the agencies, human resources records, insurance company records, and interviews with administrative, human resources, and health promotion program personnel. The director of human resources administration at IndyGo and the manager of wellness and benefits at RTS also participated in interviews and provided information for these case studies. In some cases, members of agency staff joined a conversation and/or provided data. Details on the project teamâs selection method for the sites included in the study are available in Appendices A and B. In the case of IndyGo, RTS, TARC, and DART, the project team conducted an analysis based on individual-level data to determine if statistically measurable benefits were associated with program participation. LA Metro did not provide individual-level data, so regression modeling was not possible for this location. For the analyses, baseline data were collected from before the comprehensive health and health promotion programs began. Also collected before, during, and after the program were individual records of absenteeism (both sick and personal days taken) and workersâ compensation payments. Measures of participation were collected as well. Specifically, the project team examined the relationship between wellness/health promotion programs (screenings, 5K runs, diet) and improved health outcomes (less absenteeism, fewer sick days) in four sites using linear regression analysis. The results for three sites showed no statistically significant measurable benefit, a finding broadly consistent with past studies. In one loca- tion (Des Moines) the participation effect was statistically significant at the 95% level; it was estimated that participation in the program resulted in a 4-hour decrease in absentee hours. This result was reasonably larger, but based on a small sample so it is unclear if it could be repli- cated or should be used to generalize about effective wellness program interventions. The analyses for TARC (Louisville) and DART (Des Moines) were structured somewhat differently from those for IndyGo (Indianapolis) and RTS (Rochester). For IndyGo and RTS, C H A P T E R 6 Case Studies: Health Promotion Programs

54 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the control/non-participatory group was based on a structural factor, such as whether an employee was insured or not (IndyGo) or worked at a remote location as opposed to working onsite (RTS). By contrast, the participants at TARC and DART volunteered to take part in well- ness activities and wellness screenings. In these two studies, the records on voluntary partici- pation were used to measure the correlations between outcomes and wellness programs. For IndyGo, RTS, TARC, and DART, the data were tracked so that pre- and post-analysis of effects of participation on absenteeism could be properly conducted. Because data were available on gender, race, and day of hire/termination, participation in these programs could be analyzed, as could rates of turnover and other research questions. The LA Metro case study provided information on the prevalence of health conditions from its insurance companies and detailed aggregate data on wellness program participation records. Individual-level data were not made available on absenteeism or workersâ compensation, however, so a multivariate statistical analysis was not possible. This chapter discusses process-based and data-driven benefits, though the two are not always mutually exclusive. Process-based benefits can include the diversity of the wellness committee, the array of programs, and the flexibility of the schedule. Data-driven benefits can include reduced absenteeism or workersâ compensation claims. This chapter begins with the description of the programs and more process-based benefits of the programs and follows with a discussion of estimated data-driven benefits. The case studies include scalable and sustainable strategies that have been implemented by the transit agencies. The programs have multiple features, including workshops on diet and exercise, biometric screenings, targeted education to avoid common injury types (e.g., musculoskeletal), financial planning, fitness challenges, and onsite gyms. 6.2 IndyGo This case study was developed through emails and discussions with the president of Amalgamated Transit Union (ATU) Local 1070, and the director of employee services for IndyGo. 6.2.1 Background IndyGo is a municipal corporation providing public transportation to the city of Indianapolis and surrounding Marion County, Indiana. The agency operates 31 bus routes throughout the county (IndyGo n.d.). As of 2018, it has approximately 680 employees, of whom more than 500 are members of ATU Local 1070 (Russell 2018). 6.2.2 Program Startup and Development The onsite clinic and wellness program were started on January 1, 2010, as part of a binding arbitration award between IndyGo and ATU Local 1070 in response to a pending premium increase of 46% from IndyGoâs health insurer. The steep increase was the providerâs response to the high cost of IndyGoâs medical claims. To control the increase, IndyGo management (together with the agencyâs benefits consultant and with agreement from ATU Local 1070) proposed an onsite clinic and wellness program. Given the agreement to offer the onsite clinic and wellness program, the insurance provider dropped the premium increase from the pending 46% to approximately 20%. The overall savings captured by reducing the increases in insur- ance premiums benefited the program in two ways. As an incentive to participation, the agency used some of the savings to reduce the portion of the insurance premiums paid by participating employees, and additional savings helped fund the program itself.

Case Studies: Health Promotion Programs 55 6.2.3 Work Organization/Work Environment Like many other agencies, the majority of operators (approximately 55%) at IndyGo work split shifts. For many operators, this arrangement has a negative impact on their quality of life. Unless operators invest the time and expense to acquire, transport, and store their own food, having access to healthier food choices can be challenging. Onsite vending machines available in the break rooms were not stocked with healthy options. One of the top priorities of ATU Local 1070 has been to provide adequate restroom access for operators. This quality of life issue can have meaningful consequences, both short- and long-term. Before implementing the wellness program, management and union leaders worked together to address this issue. 6.2.4 Health, Wellness, and Safety Concerns From the perspective of IndyGo management, the main health concerns concerning workersâ compensation are musculoskeletal injuries; slips, trips, and falls; and vehicle accidents. According to the aggregate data from claims reports and onsite clinic data, the top health issues on the personal health side are obesity, hypertension, diabetes, prediabetes, and asthma. To address the work-related incidents and injuries, IndyGo has been incorporating ergonomics and prevention of injury into onboarding and in-service training. The union president expressed that diabetes, sleep apnea, and hypertension are the top health and wellness issues of the represented employees. Obesity is also on the rise among frontline employees, according to the local president. 6.2.5 Program Activities/Elements The IndyGo health and wellness program was made available to employees who have insur- ance through IndyGo. In 2016, approximately 88% of all IndyGo employees were covered under group health insurance. Participation was voluntary but incentivized: If employees participated in the program, they paid half of the premium (15% of the total insurance premium) compared with employees who did not participate (30% of the total insurance premium). Because of the incentive, IndyGo reported that 97% of the employees covered under the group health insurance plan elected to participate in the program (Russell 2018). To maintain their discounts on the health premiums, employees must complete the following annually: a physical, a health risk assessment, a biometric screening, a minimum of four coaching sessions, and a health activity. Some of the physical and educational activities include gardening, a Weight Watchers program, onsite exercise classes, walkârun groups, basketball tournaments, a 5K event for runners and walkers, and financial and nutrition classes. Union leadership stated that the approach has been effective because even though parti- cipants have to complete the requirements, the focus is on self-help and learning how to properly care for your health on your own. The union has been particularly pleased with the level of involvement of the onsite clinic provider because they understand the nature of the jobs performed and have developed relationships with the employees. Participants can get advice and care based specifically on the demands of their jobs. Participation in the program primarily occurs while employees are on the clock. According to the agency, getting employees to participate outside of their shifts is difficult. Efforts have been made to hold events and wellness opportunities in the community, but these activities were not well attended. âItâs a great program. I suffer from a lot of ailments and gain weight very easily. The doctor and nurses at the Activate clinic are very personal. They helped me so much and I have seen real progress. They understand how demanding the job is and our eating habits. They define different alternatives. We have good results; people are getting more conscious about fitness. Thatâs what youâll hear from most members.â âATU Local 1070 Financial Secretary

56 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.2.6 Organization The human resources department oversees the onsite clinic and wellness program and all activities related to health program initiatives. IndyGo contracts with a third party that is staffed with two nurse practitioners, a part-time doctor, and medical assistants, and has a wellness committee composed of union and non-union employees that help design new activities and promote the program and initiatives. The program is funded through the IndyGo operating budget, which incorporates funding obtained through agreements with the union and the healthcare insurance provider. The 3-year contract with the current onsite clinic provider costs the transit system approximately $500,000 a year, including staff costs, clinic services (primary and urgent care), and expenses for some prescription drugs (as a one-time fill) (Russell 2018). 6.2.7 Qualitative Program Benefits Although the program did not have strong internal support from frontline workers initially, the president and financial secretary of ATU Local 1070 promoted the program and helped assure workers that information disclosed in the clinic would remain confidential (Russell 2018). Now, agency and union leaders report that there is total support for the program among the employees. Many employees have shared their positive experiences, including being screened for prediabetes or sleep apnea and having access to information about how to improve eating habits and lose weight. 6.2.8 Reported Metrics From 2010â2013, the average cost for health insurance per employee fell from $12,790 to $10,244. Between 2014 and 2017, the insurance provider changed and insurance costs fluctuated. In 2017 (under the new provider) the average insurance cost per employee was $13,004. As shown in Table 29, health claims rose from 2016 to 2017 (fourth column, percentage change) and appeared to be increasing at a similar rate in 2018 (sixth column, percentage change). Additional detailed information on medical claims (e.g., claims broken down by condition or claims dating back before 2015, before the wellness program began) was not received. 6.2.9 Method On June 15, 2018, after preliminary conversations, the project team provided IndyGo with a data use agreement stating that all dataâincluding human resources, payroll, and program participation and other related dataâwould be used only for the research project, would be handled and protected according to the requirements of the Federal Information Security Management Act (FISMA), and would be destroyed at the end of the research period. Claim Type 2016 a 2017 a PercentageChange January 1â June 30, 2018 Projected Percentage Change b Medical-paid claims $4,257,969 $5,078,484 19.27% $2,538,382 20.0% Prescription-paid claims $1,091,018 $1,494,763 37.01% $791,502 27.1% a Table not adjusted for inflation. The Consumer Price Index (CPI) in 2017 was 1.6% per the U.S. Inflation Calculator; in 2018 it was 1.9%. b Numbers in this column are based on the assumption that the monthly rate in the second half of the year is the same as the monthly rate during the first 6 months of the year. Table 29. Claims and prescriptions reported for IndyGo, 2016â2017.

Case Studies: Health Promotion Programs 57 On June 21, 2018, after a follow-up call with personnel at IndyGo, the project team sent an email requesting the following data: â¢ Excel files (or tab-delimited files) with downloads of the number of personal days and number of sick days with employee names, gender, date of birth, occupational code, and date of hire for 2009â2018 (or whichever historical years were available) for all employees; â¢ Excel files (or tab-delimited files) with downloads of workersâ compensation payments for 2009â2018 with employee names for all employees; â¢ Excel files (or tab-delimited files) with race and employee names for all employees; â¢ Names of participants by year in the health insurance program; and â¢ Names of participants by year in the health wellness program, among those eligible for the health insurance program. IndyGo provided payroll data with individual-level data from 2009 to 2018 on absences, including sick leave, personal leave, family medical leave, and leave without pay, as well as workersâ compensation data from 2012 to 2018. Because IndyGo introduced the health program in 2011, 2010 was established as the baseline year for the analysis, and all requests for data referenced 2010 as the first year. (Based on the initial interview, some early requests were made for 2009 data, but the agency later clarified that the program began in March 2011.) IndyGo further provided insurance information for employees from 2011 to 2018. Using the 97% participation rate in the program among those who carried insurance as a basis, the project team assumed that if employees carried insurance, they participated in the program. No other data were available on participation among those insured. The insurance information was merged with the absentee data based on the employeeâs name and birthdate. The data provided 36 categories of job descriptions, with several categories referring to different types of operators (e.g., full-time, part-time), as well as jobs with maintenance, and administrative roles. Employees were categorized as operators, mechanics, and administrative staff based on their job descriptions in the leave data; for example, fixed-routeâcoach operator and flexible services coach operator were defined as operators. Administrative roles were removed from the analysis because the focus was on the outcomes for frontline employees, which consisted of operators and maintenance staff. For the models, the project team analyzed the full-program effects: comparison of absen- teeism and workersâ compensation measures for 2010 (the baseline year) with measures for 2017 (the last full year of program data) or with the last full year that the employee was at IndyGo before 2017, if the individualâs employment was terminated in 2017 or before. Regression models were run using ordinary least squares to detect any potential correlation between participation in the health program and lower absenteeism. The dependent variable in the models was an overall absentee variable capturing total days of leave, and the inde- pendent variables were participation/insurance (the key explanatory variables) and control variables, including age, race, tenure, gender, and occupation. The regression model was run using alter native dependent variables to measure the robustness of the model and results to different specifications. Two of those alternatives were workersâ compensation dollars and the difference of absenteeism and workersâ compensation before and after the introduction of the health program. 6.2.10 Workforce Characteristics To be included in the analysis, employees had to have been employed with IndyGo for at least 1 full calendar year in 2010 and for 1 full calendar year after the wellness program began in 2011. This qualification applied to 252 records. The workforce under observation was smaller than the total workforce due primarily to missing data and high turnover. In 2010,

58 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line IndyGo had 333 frontline employees. Twenty-one employees were excluded for missing data required in the regression analysis, and 60 employees were excluded because their employ- ment was terminated before the first complete year of the program. This left 252 records avail- able for the analysis. Table 30 presents race, age, and gender breakdowns for the two employee types (operator and maintenance, separate and combined) considered in the analysis. The White population was substantially older than the African-American population: The average age for the 53 White workers was 60.1 years, compared with an average age of 53.6 years for the 220 African-American workers. The men were slightly older than the women, averaging 56.5 years of age for men compared with 52.2 years for women. The maintenance workers were older than the operators, with an average age of 58.5 years compared to 54.7 years, and maintenance workers tended to be male at a higher rate (93.1%) than did operators (56.2%). The analysis examined if outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: âever in programâ and ânever in program.â Table 31 displays the characteristics of these two groups. Based on employees having insurance through IndyGo, the average age of participants in the program was slightly younger (53.7 years) than the average age of non-participants (57.0 years). As Table 31 shows, participants in the program were overwhelmingly operators (only one maintenance worker had been in the program). 6.2.11 Absentee Hours After Program Initiation The data generated from the IndyGo health promotion program provided a wealth of new information in an area where data have been sorely lacking. Figure 5 presents the average annual absentee hours for frontline employees for the 8 years from 2010â2017. The figure illustrates the trend in absentee days, starting with the year before the program began (2010) and extending through the last full calendar year in which data were provided. The graph presents absentee hours over time for all employees (orange line), women (purple), and men Demographic Characteristic Operator Maintenance All Count Percent Age a Count Percent Age a Count Percent Age a African American 191 85.7% 53.9 7 24.1% 50.0 198 78.6% 53.6 White 31 13.9% 59.7 22 75.9% 61.2 53 21.0% 60.1 Other race 1 0.4% 60.0 0 0% N/A 1 0.3% 60.0 Female 87 39.0% 52.5 2 6.9% 48.9 89 35.3% 52.2 Male 136 60.9% 56.2 27 93.1% 59.2 163 64.7% 56.5 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 a All ages are averages. Table 30. Demographics of IndyGo frontline population, 2010. Demographic Operator Maintenance AllCount Percent Age * Count Percent Age * Count Percent Age * Ever in program 153 68.6% 53.9 1 3.4% 38.6 154 61.1% 53.7 Never in program 70 31.4% 56.4 28 96.6% 59.2 98 38.9% 57.0 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 * All ages are averages. Table 31. Program participation and age by job category, IndyGo.

Case Studies: Health Promotion Programs 59 (teal), and for African Americans (blue) and Whites (red). Absentee hours were defined as total hours of sick leave, personal leave, and sick unpaid leave. Although year-to-year fluctuations occurred for all six groups, the general trend does not demonstrate much variation. Beginning with an average of 70 hours in 2010, there was a slight increase over the 8-year period to approximately 100 hours at the end (2017), which might reflect an aging workforce. Women on average have slightly higher amount of sick leave than men, which was a trend evident among all the case study populations. Figure 6 shows the trends as plotted for the median annual absentee hours. Figure 7 presents the average annual absentee hours for frontline employees for the eight years from 2010â2017. The graph shows maintenance employees (blue), operator employees (red), and total frontline employees (orange). 6.2.12 Workersâ Compensation Table 32 shows the number of indemnity claims for the years the agency providedâ specifically, annual data for frontline employees from 2013 through 2017. These claims could not be matched with individual employees (participants or non-participants). The table 0 20 40 60 80 100 120 140 160 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Other Female Male Grand Total Figure 5. Average annual absentee hours, IndyGo frontline employees by race and sex, 2010â2017. 0 10 20 30 40 50 60 70 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Female Male Grand Total Figure 6. Median annual absentee hours, IndyGo frontline employees by race and sex, 2010â2017.

60 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line illustrates the variation from year to year in both the number of claims and the average dollar- amount per claim. Figure 8 shows the percentage of (frontline) employees with indemnity claims from 2013 through 2018, including the total of employees with claims (orange), and the percentages for various demographic groups. As discussed above, data on claims before 2013 were not available. The percentage of claims increased over the observed period; thus, there was no evidence of a reduction in claims attributable to the program during this period. The program may have caused a reduction, but other (unobserved) factors would have had to offset that reduction, causing the overall rate to rise. Note that women filed the highest percentage of claims consis- tently throughout the period. 6.2.13 Results Using regression analysis, the project team investigated using several model specifications. The analyses varied the dependent variable, changed the mix of independent variables, and tested several interaction terms. The interaction terms tested how program participation varied by some of the demographic variables. In no case was the coefficient on the effect of program participation statistically significantly different from zeroâthat is, in no case did participa- tion have a statistically significant effect on health, measured as the change in number of days absent. Variables also were included for operators and maintenance, which would have shown if one occupational group was more likely to have reduced absenteeism days associated with the program than the other group. However, variables in those regressions did not have any statistically significant effects either. 0 20 40 60 80 100 120 2010 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 7. Average annual absentee hours, IndyGo frontline employees by job classification, 2010â2017. Year Sum of Claims Unique Claims Average per Claim 2013 $122,890 125 $983 2014 $228,239 336 $679 2015 $426,234 125 $3,409 2016 $956,551 336 $2,847 2017 $49,534 64 $774 Table 32. Workersâ compensation indemnity claims by year, frontline IndyGo employees, 2013â2017.

Case Studies: Health Promotion Programs 61 Appendix C outlines some of the potential reasons for the lack of significance for the participation variables. In particular, Tables C-1 and C-2 present two regressions that are representative of the variations that were tested, and the corresponding text includes a discus- sion of the analysis. 6.3 RTS This case study was developed with input from the director of well-being and inclusion and the director of people, performance, and development at RTS, and the president of ATU Local 282. 6.3.1 Background RTS is the public transportation agency that provides service to the counties of Monroe, Genesee, Livingston, Ontario, Orleans, Seneca, Wayne, and Wyoming in New York State. The agency serves more than 17 million customers annually and employs more than 900 individuals, of whom approximately 75% are operators and maintenance employees. As the largest subsidiary of the RochesterâGenesee Regional Transportation Authority, RTS has a fleet of 216 buses (of the authorityâs total fleet of 404) and has built a reputation for on-time perfor- mance and innovative performance management (RochesterâGenesee Regional Transporta- tion Authority n.d.-c). Approximately two-thirds of RTS employees are based at the agencyâs Monroe campus, which is the location of an onsite gym and the hub of the agencyâs health promotion activities. The other employees are based at nine offsite locations remote from the Monroe campus and do not have immediate access to the gym. The employees based at the offsite locations have limited access to the agencyâs health promotion activities. The data provided by RTS and the RochesterâGenesee Regional Transportation Authority used codes to represent employees at the main locations, including the nine offsite locations: Lift Line, BBS, STS, WATS, WYTS, OTS, CATS, GTC, and LTS. 6.3.2 Program Startup and Development RTSâs health and wellness program, dubbed Healthy U, started in 2011 as a modest and loosely defined program with a focus primarily on physical fitness. It became a more 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 2013 2013.5 2014 2014.5 2015 2015.5 2016 2016.5 2017 2017.5 2018 Black or African American White Female Male Grand Total Figure 8. Percentage of employees with workersâ compensation indemnity claims, by demographic group, IndyGo frontline employees, 2013â2017.

62 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line developed wellness program in 2013 and 2014, addressing a comprehensive set of goals that were defined in 2014. With healthcare costs skyrocketing and premiums rising both for the agency and the covered employees, RTS understood that it had an opportunity and an obli- gation to help employees. The agency hired a full-time health and wellness coordinator to oversee the newly expanded program. As the program was developed, medical claims data were examined to understand the most prevalent and costly medical conditions. Combining this knowledge with information about the demographics of the frontline employees, RTS staff members crafted the initial focus of the program. The agency conducted a survey in 2014 to understand the needs of transit employees, the types of programs they would be most likely to participate in and benefit from, and the most convenient times to hold events. The agency received 153 responses to the survey. In 2018, RTS conducted a similar survey to gather feedback on the wellness program. The latter survey asked respondents whether they had participated in wellness activities in the past and asked respondents to identify what would motivate them to participate in the future and whether there were any barriers that prevented their participation. This survey found that 52 respondents had participated in previous health promotion activities (RTS 2018). 6.3.3 Work Organization/Work Environment At RTS, almost all operators work split shifts (either two or three shifts). Generally, employees are on the clock between 9 hours and 12 hours, including breaks between runs. The maximum amount of time behind the wheel is 12 hours, however, and the maximum shift time is 15 hours. Bus maintenance requires coverage 24 hours a day, 7 days a week. Approximately 10% of bus technicians work split shiftsâtwo sets of scheduled times within a 7-day span. A tech- nician may work, for example, from 11:00 a.m. to 7:00 p.m. for three days, then from 3:00 p.m. to 11:00 p.m. for the remaining days of the work week. Vacation time is based on accrued personal time, and vacation leave is approved and sched- uled for the entire upcoming year. Every employee also is allowed nine sick time and/or unapproved absences per year. If the number of unapproved absences exceeds nine, employees enter disciplinary action. Operators can apply for approved time off by putting in their name and the requested date(s). As long as the employee has sufficient accrued time to cover the requested leave, approved time off does not count as an unapproved absence (RTS 2018). Shift work and varied schedules have an impact on workersâ access to healthy food and sleep patterns. Employees working overnight shifts have access to vending machines onsite, but due to the hours, the availability of alternative healthy food options is limited in the community. Sleep schedules also can be impacted by working overnights. Many bus cleaners who work overnight shifts also work a second job during the daytime, which can result in added stress, limited access to healthy food and healthcare services or support, and irregular meal times. RTSâs health insurance provider issues annual data showing the prevalence of health condi- tions. The top three conditions for 2017â2018 were hypertension (affecting 25.1% of the insured population), cholesterol disorders (16.8%), and back and neck problems (10.2%). The union president considers sleep apnea, diabetes, hypertension, and muscular issues (primarily back and shoulder) as the primary reasons leading to potential medical disqualification among operators (Chapman, personal communication, 2018). The union also cited anxiety and stress and poor nutrition as the top health and wellness concerns.

Case Studies: Health Promotion Programs 63 6.3.4 Program Activities/Elements Healthy U has promoted healthier behavior and habits among RTS employees by providing a comprehensive set of new offerings and services and changing existing services to align with the goals of the program. Many of the adjustments have focused on food because this is an accessible way to build relationships with employees. The new programs and offerings were designed to be convenient and fun to encourage participation (e.g., short workshops in the break room, bowls of fresh fruit, team activities). The program also prompted changes to regular events and services that employees engage with (e.g., by providing healthier choices in vending machines and at employee events). RTS has made efforts to provide services that fit into the daily schedule of its employees. Agency employees have 24/7 access to a wellness center that includes a gym. Employees also can make individual appointments with a health and wellness coordinator. The health and wellness coordinator works full time, which provides some flexibility for operators and other employees with off-hour shifts. The program also offers vouchers that employees can use to obtain produce from a local farmerâs market at their convenience. Employeesâ schedules, which are characterized by working shifts around the clock and on weekends, inhibit their participation in various parts of the wellness program. The wellness team and coordinator have tried to create programs that can be used at any time, with the hope of making it as easy as possible to engage all employees, regardless of what shifts or days they work. There is no feasible way to make the program accessible to everyone all the time, however. RTS promotes the Healthy U program through newsletters, posters and flyers, email blasts, paycheck attachments, and home mailings. Employees also can find information on the agencyâs intranet (Rochester Business Journal 2016). One of the most effective ways of promotion is through the support and engagement of the agencyâs Wellness Committee, whose members keep their coworkers and teams up to date on activities and eventsâand encourage their coworkers to participate. From each regional property, the RTS regional manager selects one employee (who may have a personal interest in wellness or be interested in a develop- ment opportunity) to participate as a wellness champion. Wellness champions participate in a monthly conference call to share ideas and collaborate on wellness-related topics, outreach, and events. Wellness champions do not receive extra compensation for their participation. The president of ATU Local 282 helps communicate information about the program to the unionâs members. 6.3.5 Organization The People Department (Human Resources Department) manages RTSâs health and well- ness program, which employs the full-time wellness coordinator. The Wellness Committee is staffed by representatives from every division and meets once a month to oversee the program. This committee is made up of 16 employees, including one ATU member, and two representa- tives from the agencyâs health insurance provider. Participation in the Wellness Committee is voluntary and members are not compensated extra. The President of ATU Local 282 also is personally involved in many health and wellness events organized by the agency. RTS has recently enacted a âCommitment to Diversity and Inclusion,â which the agency posits will impact the overall health and well-being of the organization and all employees by creating a more inclusive atmosphere that favors respect and relationships. A council of 16 employees, of whom 7 are frontline workers and ATU members, is responsible for carrying out the new effort, working in tandem with the wellness committee. Example of Sustainable, Successfully Implemented Strategy â¢ Connecting around food: â¢ Fresh fruit in breakrooms and common areas; â¢ Snack of the month; â¢ Short workshops on nutrition and cooking; â¢ Healthier vending machine choices; â¢ Catered employee events featuring âgood-for-youâ options; â¢ Voucher program for local farmerâs market and other onsite experiences.

64 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.3.6 Resources The Healthy U program relies on third-party providers and community partners for many of the services offered. RTS funds the program through its operating budget. In fiscal year 2017â2018, the program budget was $24,320, not including the salary for the wellness coor- dinator (RochesterâGenesee Regional Transportation Authority n.d.-a). The budget covers these key categories: blood pressure kiosks onsite; equipment and supplies for the wellness center (onsite fitness facility); health screenings; food for events; promotional items; well- ness initiatives linked to claims management; and other wellness initiatives and employee engagement. For fiscal year 2018â2019, the budget was increased by $17,000 (a substantial 70%) to $41,320. 6.3.7 Qualitative Program Benefits From the perspective of the agency, the wellness program has been a successful endeavor. It has brought the organization together and fostered greater employee engagement. Despite the lack of financial incentives for participation, program engagement and utilization have increased. According to the director of well-being and inclusion, one of the greatest difficulties regarding the participation of operators is scheduling. The majority of RTS bus operators work in shifts with prolonged breaks in between, but the breaks seldom align with planned wellness events. Some success has resulted from efforts to encourage supervisors to communicate with operators and promote the program by word of mouth. According to the union president, operators that have schedules consisting of three shifts participate in wellness events to a lesser extent because of the length of their workdays. Employees with irregular work schedules find it easier to participate in events that are sched- uled on weekends or programs that are available to employees at their discretion (including the produce voucher program). Increased physical activity due to the availability of the gym is the most apparent benefit of the program, though only employees that work at the Rochester campus use it regularly due to the proximity. 6.3.8 Reported Metrics The project team examined statistics from RTSâs health insurance provider (Table 33). As seen in the table, the prevalence rates of most of the major disorders that occur in the transit worker population showed slight increases among RTSâs insured population. Because the aggregate figures provided included administrative workers and covered dependents as well as frontline workers, it was not possible to isolate the effects of participation in the wellness program. Participation in the wellness program may have mitigated increases in prevalence âRTS wants our employees to thrive and live the healthiest lives they can. The RTS Healthy U wellness program fosters a culture of health and well-being within our organization and community by empowering our employees to make healthy lifestyle choices. The strategic initiatives we are implementing for the wellness program will support employees by providing education, resources, support, and access to programs and services that are fun, engaging, and sustainable. Healthy U brings employees together on their wellness journey and celebrates their successes.â âRenee Ellwood, Director of Well-Being and Inclusion Disorder 4 Years Prior Current Change General Population (Excellus) Cholesterol disorder 30.2% 29.0% â1.2% 18.9% Hypertension 38.8% 41.9% 3.1% 23.2% Diabetes 15.4% 16.7% 1.3% 8.1% Back and neck problems 8.5% 12.9% 4.4% 14.9% Depression and anxiety 5.3% 5.9% 0.6% 9.6% Source: Table as provided by RTS via personal communication (Excellus 2018). Table 33. Comparison of rates of major health disorders, RTS insured population to general population, 2012â2017.

Case Studies: Health Promotion Programs 65 among the frontline workers that were part of a more general health trend; however, lacking the necessary granularity in the data, that hypothesis could not be assessed. RTS continues to conduct ongoing review and analysis of the health claims data and monitor wellness initia- tives against claims data (RochesterâGenesee Regional Transportation Authority n.d.-b). In addition to health claims data, new conditions are identified through free, onsite health screenings. RTS seeks to educate and bring awareness to employees about potential health risks and to prevent or manage them. The focus on prevention has resulted in the identifica- tion of more employees with health risks, but this identification has also made it possible for employees to help manage those risks, using the Healthy U wellness program to make healthy lifestyle choices. The program also has focused on the importance of managing health condi- tions and prescriptions, as well as actively using the comprehensive health and wellness benefits provided to employees (e.g., insurance coverage for medical, dental, and vision services, and other employee benefits related to financial wellness and retirement planning). 6.3.9 Method The project team provided RTS with a data use agreement, and data received from RTS associated individuals with their employee ID numbers, thereby protecting their identities. Following conversations with relevant staff members, the project team emailed a list of the absenteeism, workersâ compensation, and demographic data requested. In August 2018, RTS began providing the project team with individual-level payroll data on absences and workersâ compensation. RTS provided absenteeism and workersâ compensation data from 2011 to 2018 for both onsite and offsite employees. Files of employeesâ demographic information were provided, as well as hire and termination dates. This information was merged with the absentee data based on the employee ID. Because RTS had indicated that it introduced the health program as a comprehensive program in 2014, 2013 was used as the baseline year for the analysis. Payroll information was made available for more than 1,000 employees who had worked for RTS over the 2010â2017 period. Approximately 650 employees were onsite and had the easiest access to the health program. The entity code âRTSâ was used to identify employees who were onsite and had access to the health program, whereas the rest of the employees were combined into a control group of âoffsiteâ employees who were assumed to have limited-to- no-participation in the program. The data provided 282 categories of job descriptions, with several categories referring to different types of operators, maintenance, and administrative roles. Employees were catego- rized using the âAssignment Titleâ provided with their demographic information. For example, employees with the title bus operator were defined as operators, whereas an employee with the title workforce development manager was defined as administrative. Employees often had multiple assignment titles without a date-of-job change. To determine the job description, the project team selected the last available job title that was not retiree. Trainee was selected as the job title only if it was the only title available. Administrative roles were removed from the analysis, which focused on the outcomes for frontline employees (consisting of operators and maintenance staff). Multiple variables of interest were compared, including use of sick days, unpaid leave, and personal days. At RTS, employees acquire sick leave and personal leave at varying rates based on seniority; up to 120 days of sick leave can be accumulated (Hall, personal communication, 2018). For each variable, the difference in use before and after the introduction of the health pro- gram was examined. Multiple regression and other statistical analyses were run to find a relation- ship between participation in the health program and lower absenteeism.

66 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line In the model, the dependent variable was a total of sick days, unpaid leave, and personal days. The key independent variable was participation in the health program. The other inde- pendent variables controlled for age, race, tenure, gender, and occupation. The regression model also was run using the difference of the dependent variable before and after the intro- duction of the health program as the dependent variable. No statistically significant results were found. Details of the analysis are provided in Appendix A. 6.3.10 Workforce Characteristics In 2011, a limited version of the program was introduced, but the comprehensive version of the program was not rolled out until 2014, so the project team chose 2013 to be the base- line year for this analysis. Of the 574 frontline workers (operators and maintenance) who were employed in 2013, 389 workers (approximately 68%) were based at the main location where the gym and wellness programs were held, whereas 185 workers (32%) were based at remote locations. The project team designated the 389 workers at the main location as the participants because they had greater exposure to the programâs core elements. The 185 offsite employees were considered the control group of non-participants. Table 34 presents the averages for the total population of frontline employees, broken down separately for operators and maintenance employees. The first demographic detail that stands out is the same as for IndyGo: The White popu- lation is substantially older than the African-American population. The average age for the 300 White workers that were operators or in maintenance was 60.2 years, compared with the average age of 53.0 years for African-American workers. Men were slightly older than women, with an average age of 57.1 years compared with 54.3 years. As in Indianapolis, the population of maintenance workers was almost all male (106 out of 108 workers). The analysis method was to examine how outcomes related to absenteeism were related to program participation. Thus, the analysis divided the population of frontline employees into two groups: onsite and offsite. These groups represented the workers who participated in the program and those who did not. The characteristics of the two groups are displayed in Table 35. The average age of offsite operators (61.0 years) exceeded that of onsite operators (54.3 years). The average age of offsite maintenance workers (55.0 years) was only slightly lower than that of onsite maintenance workers (55.8 years); however, the vast majority of maintenance workers were onsite, with 101 of the 108 workers on location at the main campus. Calculating the total Demographic Characteristic Operator All Count Percent Age * Count Percent Age * Count Percent Age * White 237 50.9% 61.0 63 58.3% 57.3 300 52.3% 60.2 African American 183 39.3% 53.1 36 33.3% 52.4 219 38.2% 53.0 Hispanic and Latino 2 0.4% 60.5 0 0.0% 0.0 2 0.3% 60.5 Two or more races 2 0.4% 66.0 0 0.0% 0.0 2 0.3% 66.0 Native American 1 0.2% 41.0 2 1.9% 52.0 3 0.5% 48.3 Asian 41 8.8% 48.6 7 6.5% 58.3 48 8.4% 50.0 Female 117 25.1% 54.3 2 1.9% 53.0 119 20.7% 54.3 Male 349 74.9% 57.6 106 98.1% 55.7 455 79.3% 57.1 All 466 100.0% 56.8 108 100.0% 55.6 574 100.0% 56.5 * All ages are averages. Maintenance Table 34. Demographics of RTS frontline population, 2013.

Case Studies: Health Promotion Programs 67 populations of offsite workers (non-participants) and onsite workers (participants), the offsite workers were older (60.8 years) than the onsite workers (54.7 years). (The calculated numbers do not appear in the table.) 6.3.11 The Program Over Time As with IndyGo, data generated from RTSâs health promotion program has provided new information to assess the patterns of absenteeism of transit workers. Absenteeism days are defined as total hours of sick leave, unpaid sick leave, and paid and unpaid personal leave. Between 2011 and 2017, the total hours taken increased from approximately 40 to 60 hours per year. Figure 9 presents the average annual absentee hours for frontline employees for a 7-year period (2011â2017). The baseline in this analysis is 2013 and the comprehensive program began in 2014, but this case study includes some available data from 2011 when the health promotion program was introduced in a limited form. Figure 9 includes absen- teeism data from the early years of the program, before it was fully established (2011â2013), and from the subsequent years (2014â2017) that reflect absenteeism after the program was fully developed. The data in Figure 9 show that Whites had higher rates of absenteeism than did African Americans and that the rate of absenteeism among women was similar to that of men (not greater, as was the case at IndyGo). The data in Figure 9 have not been controlled for age. Figure 10 shows trends related to absenteeism by job category for operations, maintenance and all workers. As seen in the figure, during the period examined (2011â2017), maintenance workers had a higher average number of hours absent than did operators. Factor Operator Maintenance Offsite Onsite Offsite Onsite Number 178 288 7 101 Percentage 38.2% 61.8% 6.5% 93.5% Average age 61.0 years 54.3 years 55.0 years 55.8 years Table 35. Program status and age of RTS frontline population, 2013. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Black or African American White Hispanic or Latino Female Male Grand Total Figure 9. Average annual total absentee hours, RTS frontline employees by demographic characteristics, 2011â2017.

68 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 11 presents the average annual total of absentee hours for RTS frontline employees for 2011â2017. On average during this 7-year period, onsite employees used fewer sick days then did offsite employees. 6.3.12 Workersâ Compensation Whereas Figures 9, 10, and 11 show trends related to absenteeism, Table 36 uses data provided by RTS to illustrate trends related to workersâ compensation over the same period (2011â2017), although data for 2013 and 2014 were not available. Table 36 presents workersâ compensation indemnity claims for the period and the average cost per unique claim. Table 37 includes the estimated number of days of workersâ compensation paid for all claims and the average number of days per claim. The claim percentage rate in 2011 (before program implementation) was 8%, and the percentage rate also was 8% in 2016â2017, well into the program. The percentage rose to 11% in 2012 but was reduced to 5% in 2015 (the next available year). The linear downward trend may indicate some effect due to the wellness programs, particularly if other (undocumented) factors were working at the same time to increase the percentage. It was not possible to statistically test these possibilities. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 10. Average annual total absentee hours, RTS frontline employees by job classification, 2011â2017. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Offsite Onsite Grand Total Figure 11. Average annual total absentee hours, RTS frontline employees by work location (onsite/offsite), 2011â2017.

Case Studies: Health Promotion Programs 69 Total workersâ compensation days were calculated based on the 2017 average wage for 731 RTS operators and maintenance workers of $24.32 and the workersâ compensation payment of 66.67% of that wage to fully disabled workers in the state of New York. 6.3.13 Results Several variations of the linear regression were performed, the results of which are presented in Appendix A. The project team varied the dependent variable (e.g., sick day, total leave days), changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., onsite as interacted with various demographic variables). In no case was the coefficient on the effect of program participation statistically significantly different from zero. Similarly, in no case did participation have a statistically significant effect on health, measured as the change in days absent. Appendix C discusses potential reasons for the lack of significance for the participation variables and Table C-3 presents representative regression results of the variations run, accompanied by analysis. 6.4 TARC This case study was developed with the input of the president of ATU Local 1447 and the benefits manager at TARC. 6.4.1 Background TARC provides public transportation to greater Louisville, Kentucky, and the surrounding counties of Clark and Floyd in Indiana. The agency was founded in 1971 after legislation allowed the use of local funding from city and county governments to operate mass-transit systems (TARC n.d.). Table 36. Workersâ compensation indemnity claims at RTS, 2011â2017. Year Sum of Claims Unique Claims Average Cost per Claim 2011 $77,532 36 $2,154 2012 $225,487 47 $4,798 2013 Unavailable Unavailable Unavailable 2014 Unavailable Unavailable Unavailable 2015 $116,875 29 $4,030 2016 $512,173 46 $11,134 2017 $638,591 50 $12,772 Table 37. Workersâ compensation indemnity claims and calculated absentee days at RTS, 2011â2017. Year Unique Claims Frontline Workers Percentage With Claims Total Indemnity Claims Total Workersâ Compensation Days Average Days per Claim 2011 36 447 8% $77,532 604 16.8 2012 47 447 11% $225,487 1756 37.4 2013 N/A 468 N/A N/A N/A N/A 2014 N/A 531 N/A N/A N/A N/A 2015 29 549 5% $116,875 910 31.4 2016 46 582 8% $512,173 3,988 86.7 2017 50 592 8% $638,591 4,972 99.5

70 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.4.2 Program Startup and Development The employee wellness program began in 2015 with the goal of changing workplace culture as prompted by an observed need for smoking cessation programs. The agency was further motivated to start a program that would reduce health insurance claims, which were relatively high. In 2015, TARC began offering smoking cessation classes, bringing together a motivated group of individuals that evolved into a more organized health and wellness committee. 6.4.3 Work Organization/Work Environment Many operators at the agency work split shifts, which can take up a majority of the employeeâs time, although breaks can be scheduled that allow for meals or time at the gym. Operators feel that they have time for little else besides resting for the next day. Operators can request specific shifts at three points during the year, when shifts are scheduled. Eligible operators also have the option of working four 10-hour runs and taking weekends off plus one additional day off during the week. Parameters for split runs are governed by the bargaining agreement with the union, and during the period examined by the project team TARC was well under the threshold designated for split runs. From the perspective of the union president, the agency has prioritized restroom access for operators; this issue has improved over time. According to management, the agency has worked to establish ample restroom stops on every route. 6.4.4 Health, Wellness, and Safety Concerns According to the prevalence rates reported by TARCâs health insurance company, the five most prevalent health concerns by number of members (employees and family members) for 2015â2018 were hypertension, hyperlipidemia, back pain, osteoarthritis, and diabetes. In interviews with TARC management, obesity-related diseases were a common concern. TARC reported approximately 15â20 short-term medical disqualifications per year. The disqualifi- cations increased over the period examined, mostly due to non-compliance with sleep apnea requirements. According to the union president, the top health and safety concerns are passenger assaults on operators, operator injury resulting from equipment in the bus or accidents involving the bus, and breathing in harmful fumes. According to the union president, these health concerns are not addressed in the wellness program because they are categorized primarily as âsafetyâ concerns and are dealt with separately under the joint safety committee. (Hamilton, personal communication, 2019). 6.4.5 Program Activities/Elements TARCâs wellness program activities have been based on survey responses from employees indicating the activities they would be interested in. Though the initial program was developed around smoking cessation, this is no longer a primary focus of the program, and was not an item that received interest in the most recent employee survey. Currently, the program consists of events and programs organized around a theme of interest, an annual corporate games weekend, and a boot camp program. Tracking data on participation has been an area of difficulty for the agency, but TARC has seen some success in encouraging participation by offering incentives and prizes to participants. According to the agency, these items are low cost ways to promote participation and camaraderie. TARC has also invested in creating onsite fitness centers at each of the agencyâs main facilities, which the agencyâs health insurance company has rewarded by issuing a premium refund to the agency and employees. Highest-scoring items from employee interview survey: â¢ Walking to increase physical activity, â¢ Having healthy snacks available for purchase at work, â¢ Increasing my physical activity level, â¢ Participating in âtastingâ events, and â¢ Learning about healthier food choices and portions to help manage my weight.

Case Studies: Health Promotion Programs 71 Specific program activities include weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreen- ings. A point system for participation allows employees to earn small prizes, such as exercise accessories, gear, or gift cards. 6.4.6 Organization The employee wellness program is led by a six-person health and wellness committee made up of representatives from TARCâs Human Resources Department and members of ATU Local 1447, including its president, an operator, and a mechanic. The committee meets every other month to determine upcoming program elements and themes. According to the union president, the relationship between labor and management regarding the program is cooperative. The union encourages participation in wellness program events and activities. 6.4.7 Resources The employee wellness program is funded through TARCâs Human Resources Depart- ment. In fiscal year 2018, $10,000 was budgeted for the agencyâs fitness centers and wellness program. The wellness program also has relied on the portion of the health insurance premium refund retained by the agency after premium refunds were distributed to the participating employees. 6.4.8 Qualitative Program Benefits The union president said that the program has been effective in promoting physical activity, although it is not clear whether the employees who have participated are those who would already be active independent of the program. Events are primarily attended by the same group of people, and the program has not broadly affected the employee population. Management at TARC noted that the activities promote team building and encourage a more cooperative work environment. Aside from health outcomes, the program sends a message to the employees that health and wellness are priorities for the agency. 6.4.9 Participation Metrics Participation in several of the activities increased from 2017, the programâs first year, to 2018. For example, participants in the corporate games event rose from 25 in 2017 to 43 in 2018, a significant increase. Data from TARCâs health insurance provider also showed a growing level of involvement since the beginning of the transit agencyâs wellness program. Participants are given points for reaching certain levels under the âHumana Goâ program (blue, bronze, silver, gold, and platinum). Total participation increased from 84% of all health insurance subscribers (not including dependents and spouses) in 2016 to 94% in 2018. 6.4.10 Workforce Characteristics A total of 338 frontline operators and maintenance workers were employed in 2015 (at the time the program was introduced). Following the programâs rollout in 2016, of these 338 workers 13 employees had attended boot camps, 49 employees had a âhighâ Humana Go level (i.e., bronze, silver, gold, or platinum level), and 54 employees had attended a bio screening.

72 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line The project team selected these participation variables for analysis because they had the highest participation numbers of the numerous activities included in TARCâs health program. Table 38 presents demographic characteristics for both the total population of TARCâs frontline employees and for the agencyâs operators and maintenance employees in 2015. As seen in Table 38, the White population was slightly older than the African-American population. The average age for the 108 White workers was 54.1 years, compared with 51.1 years for the 230 African-American workers. Men were slightly older than women, with an average age of 53.7 years for men compared with 49.8 years for women. The table replicates the pattern observed at IndyGo and RTS, where the majority of the maintenance workers were male. The project team used the data from TARC to further examine how outcomes related to absenteeism were related to participation in the program. To be counted, the workforce under observation in the two analyses performed had to have been employed with TARC since 2015, and their employment had to include at least 1 full calendar year during the period 2016â2017. In this case, multiple measures of participation (key independent variables) were used, and analysis was conducted to see if each one individually was associated with a change in absenteeism. Each category of participation was represented by groups with characteristics, as displayed in Table 39. As shown in Table 39, 13 employees participated in boot camps; these participants had a younger average age (45.3 years) compared to the non-participants (52.3 years). Forty-six employees had an elevated (silver-level or gold-level) Humana Go participation status, and Table 38. Demographics of TARC frontline population, 2015. Demographic Characteristic Operator Maintenance All Employees Count Percent Age * Count Percent Age * Count Percent Age * African American 228 80.6% 51.2 2 3.6% 44.0 230 68.0% 51.1 White 55 19.4% 55.6 53 96.4% 52.6 108 32.0% 54.1 Female 135 47.7% 49.8 1 1.8% 54.0 136 40.2% 49.8 Male 148 52.3% 54.1 54 98.2% 52.2 202 59.8% 53.7 Total 283 100.0% 56.8 55 100.0% 55.6 338 100.0% 56.5 * All ages are averages. Table 39. Program participation and age of TARC frontline population, 2016â2017. Program Participation Operator Maintenance All Count Percent Age * Count Percent Age * Count Percent Age * Key independent variable: participation in boot camps Participated in boot camps 4 1.4% 45.3 9 16.4% 52.4 13 3.8% 50.2 Key independent variable: elevated (gold, silver, or platinum) Humana Go status Base Humana Go status 245 86.6% 52.8 47 85.5% 52.8 292 86.4% 52.8 Elevated Humana Go status 38 13.4% 48.4 8 14.5% 51.8 46 13.6% 48.4 Key independent variable: attended bioscreen Did not attend bioscreen 241 85.2% 52.4 45 81.8% 52.7 286 84.6% 52.5 Attended bioscreen 42 14.8% 50.9 10 18.2% 52.3 52 15.4% 50.9 Total 283 100.00% 52.2 55 100.00% 52.6 338 100.00% 52.5 * All ages are averages.

Case Studies: Health Promotion Programs 73 these participants were younger on average (48.4 years) compared to employees who had a base (blue) level of participation (52.8 years). Fifty-two employees participated in bioscreens, and again had a younger average age (50.9 years) than employees who did not participate (52.5 years). In general, the employees who participated in the wellness program activities tended to be younger than those who did not participate. The Humana Go program was sponsored by the insurer. Employees received points for their participation in wellness program activities, including bioscreens. The points were added up to reach defined levels under the Humana Go program, progressing from blue (the base level) through bronze, silver, and gold, to platinum (the highest level). As an incentive to participation, employees also could earn prizes based on the points they accumulated (partici- pation level). 6.4.11 The Program Over Time Figure 12 presents the average annual number of absentee hours for frontline employees over the 4 years from 2015 through 2018. This analysis used 2015 as the baseline year because the comprehensive wellness program began in 2016. Only one pre-program data point was available, so the data shown in Figure 12 should be interpreted cautiously. Absenteeism days were defined as total hours of sick leave, personal leave, and unpaid leave. As the figure shows, the total average annual absentee hours increased from about 45 hours in 2015 to about 60 hours in 2018. It further shows that women had higher rates of absenteeism, which also was seen in other case studies. Figure 13 presents the average number of annual absentee hours for TARC operators and maintenance workers over the same period, compared to the averages for all frontline employees (Grand Total). As seen in Figure 13, operators consistently had a higher average of total annual absentee hours than did maintenance workers. Again, for all frontline workers, the average annual total absentee hours ranged from about 45 hours in 2015 to about 60 hours in 2018. 6.4.12 Workersâ Compensation Table 40 shows the number of indemnity claims by year from 2015â2017, with partial-year information from 2018 (the 4 years provided by the agency). It was not possible to associate claims with the individual/participant in the health claims, so a regression analysis examining the relationship between changes in claims and participation was not conducted. Figure 12. Average annual total absentee hours, TARC frontline employees, 2015â2018. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Black or African American White Female Male Grand Total

74 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Table 40 demonstrates a trend commonly seen across the case studies, which was that indemnity claims were variable and subject to fluctuation due to factors such as a few high claims. In the case of TARC indemnity claims, the table also shows that the number of unique claims is not much higher than the number of employees with claims, indicating that the instance of repeat claimants was not large. 6.4.13 Results Many variations of the linear regression were performed. The project team varied the dependent variable, changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., boot camp participation or Humana Go level interacted with various demographic variables). In no case was the coefficient on the effect of program participation significantly different from zero, and in no case did participation have a statis- tically significant effect on health (here measured as the change in days absent). Appendix C presents the results of the linear regression analysis, and within the appendix Tables C-4 (Humana Go), C-5 (boot camp), and C-6 (bioscreens) present representative regression results of the various models. 6.5 DART This case study was developed with the input of the human resources manager and chief human resources officer for DART, and the president and business agent of ATU Local 441. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Operator Maintenance Grand Total Figure 13. Comparing average annual total absentee hours for TARC operators, maintenance workers, and all TARC frontline workers, 2015â2018. Table 40. Workersâ compensation indemnity claims by year, TARC, 2015â2017 and part of 2018. Year Sum of Claims Unique Claims Average Cost per Claim Employees With Claims 2015 $498,767 63 $7,917 58 2016 $458,357 63 $7,276 60 2017 $1,033,219 76 $13,595 69 2018, JanuaryâMay $260,673 36 $7,241 35 Total $2,251,016 238 $9,458 222

Case Studies: Health Promotion Programs 75 6.5.1 Background DART is the first regional transit authority in Iowa created under state legislation and was approved in 2005. The agency operates the largest transit system in Iowa, providing more than 15,000 trips per day with a fleet of approximately 145 buses. DART is expanding throughout its service area, introducing more express, shuttle, and weekend service hours. DART also has one of the largest vanpool programs in the Midwest, with more than 100 vans (Iowa DOT n.d.). More than 280 individuals are employed at DART, including its fixed-route and paratransit operators, maintenance and facilities staff, and administration (DART n.d.-b). Taking advantage of a change in leadership within both the labor union and the transit agency management, DART has worked to encourage employees to enroll in the existing health savings account plan and make lifestyle changes. In 2017, DART implemented a comprehensive wellness program for all employees. 6.5.2 Program Startup and Development DARTâs annual wellness program began in October 2017. Before developing this program, the agencyâs only targeted wellness-related activities were biometric screenings and health risk assessments (HRAs) (McMahon, personal communication, 2018). These programs started 2 years before the current wellness program. DART has promoted a rigorous safety program since 2007 and was recognized by APTA in 2011 for its achievements in building a strong safety cul- ture (DART 2011). The development of the wellness program indicates a shift toward a more holistic approach to the health and safety of its employees. The wellness program was begun for several reasons, including a high number of workersâ compensation claims, low morale, and low employee engagement, and to boost awareness of and participation in the existing wellness screening program and HRAs (McMahon, personal communication, 2018). To structure the program to best suit the needs of the employees, a wellness interest survey was given to employees before the program inception. Ninety percent of employees parti- cipated in the survey; the program was designed and budgeted based on their responses (McMahon, personal communication). A total of 201 survey responses (182 complete, 19 partial) were received in which employees identified desired topics, the length of activities, and most convenient times of the day for activities to take place (McMahon, personal communication). 6.5.3 Work Organization/Work Environment The union has worked with management to improve shifts for operators and therefore reduce the impacts of difficult working hours. The majority (53%) of operators work split shifts, arriving at 5:00 a.m. and working until 8:00 a.m. or 9:00 a.m., after which they break until 2:00, then work again until 6:00 p.m. Efforts have been made to reduce the length of the break between shifts. The union has been bargaining for better scheduling and has worked with management on this issue because it helps with worker retention. Maintenance workers have more standard shifts, working 8-hour or 10-hour shifts with a break scheduled midway during the shift. Restroom access for operators has been a longstanding issue. Management adjusted operator routes due to complaints of urinary tract infections caused by not being able to use the rest- room when needed. Recovery time is now spent at the station, so operators have access to the restroom there. Another issue for operators is proper positioning and type of seat. In 2016, DART bought new seats for their buses and allowed operators to choose the model. The agency also redesigned DART Program Elements â¢ Monthly topics incorporated into the wellness program: back care, cold/flu prevention, diabetes, financial wellness, healthy cooking/ eating, heart health, physical activity, sleep management, stress management, and weight management; â¢ All topics chosen based on survey responses indicating employee interests; â¢ Two to three workshops per month (at DART); â¢ One to three wellness challenges per month that focus on making lifestyle changes (outside of DART); â¢ UnityPoint available at main campus or Central Station location once per month for coaching in operator lounge; and â¢ Gifts/prizes based on participation. DART Survey Response: How Long Should Wellness Activities Last? Most employees believe activities should last between 30â60 minutes, depending on the activity. Averaged across all activities, 41.1% of respondents indicated that activities should last 30 minutes; 20.0% of respondents indicated they should last 45 minutes, and 22.9% of respondents indicated they should last 60 minutes.

76 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the wheelchair securement stations so that they require less bending and stooping and allow more room to maneuver (reducing lower back pain). When operators have specific complaints about the seat, they are addressed. Often this is done by readjusting the seat or teaching the operator how to do so. The agency also implemented job offer testing to make sure that opera- tors are physically able to do all functional aspects of the position. Approximately 65%â70% of all frontline employees participate in the agencyâs health insurance plan. DART requires an annual bioscreening for every employee enrolled in the health insurance plan. 6.5.4 Health, Wellness, and Safety Concerns The union stated that the most prevalent health concerns among its members were chronic pain from the demands of the job (e.g., back pain, injuries resulting from repetitive motion); high blood pressure; and metabolic disease (e.g., diabetes). The agency had a slightly different perception of the top health and safety issues, stating that the top three were weight management, cardiovascular health, and effects of the job (e.g., ergonomics/fatigue/stress management). The agency stated that their rates of medical disqualification among operators were low, but among those that had been disqualified, the primary reasons were diabetes and soft-tissue injuries, usually occurring in the shoulder due to repetitive movement. 6.5.5 Program Activities/Elements According to DART, the program does not focus on any one aspect of health and wellness but rather on caring for the whole person. To that end, the program is multifaceted, incorporating many different topics and methods of approach. DART has engaged insurance providers, financial planners, and registered nurses to deliver workshops and provide coaching and advice to participants (McMahon, personal communication, 2018). A monthly theme is chosen that corresponds with the interests recorded by employees in the initial survey. To complement the theme, two to three monthly workshops are given at DART, as well as one to three wellness challenges that encourage participants to make lifestyle changes. Participation is incentivized with gifts and prizes ranging from sports equipment to gift certificates. Rewards are given for attending workshops and completing the monthly wellness challenges. Participants receive a reward based on the tier they have reached at the end of the program: Tier 1 is reached by attending three workshops and completing three challenges; Tier 2 is reached by attending six workshops and completing six challenges; and Tier 3 is reached by those who attend all workshops and complete all challenges (McMahon, personal communication, 2018). Outside of the events organized as part of the program, the agency has implemented several policies to improve the work environment. DART has created a new vending program so that fruit, vegetables, eggs, and protein bars are available instead of the more common snacks found in vending machines. The agency also hired specialists to analyze the buses and create cards illustrating the stretches appropriate for operators and their environment. Frontline employees are not paid for the time they spend at wellness events. This has caused some reluctance among operators and maintainers to attend events. Administrative employees attend the events during their workday, and are therefore being paid for their time. 6.5.6 Organization The wellness program relies on the planning and support of a seven-member wellness committee. Positions are open to all departments within DART. The committee meets every month to prepare for the following month and make changes and adjustments to the program as needed. Currently, the committee is staffed by the human resources manager, an operations DART Survey Response: Topics of Interest â¢ Back care, â¢ Cold/flu prevention, â¢ Diabetes, â¢ Financial wellness, â¢ Healthy cooking/eating, â¢ Heart health, â¢ Physical activity, â¢ Sleep management, â¢ Stress management, â¢ Weight management, â¢ Menâs and womenâs health, and â¢ Understanding medical insurance and other benefits offered at DART. DART Wellness Committee â¢ Seven members, â¢ Committee members from all departments, and â¢ Monthly meeting to prepare for next month and make changes/ adjustments.

Case Studies: Health Promotion Programs 77 instructor, two fixed-route operators, a maintenance employee, an operations supervisor, and a transit planner (McMahon, personal communication, 2018). The wellness committee and the program have the support and participation of the local union thanks in part to the member- ship of its president, a fixed-route operator, on the wellness committee (McMahon, personal communication, 2018). 6.5.7 Resources DARTâs wellness program has a relatively low budget (approximately $5,000 annually) and has relied on existing staff to manage the program rather than hiring dedicated staff. For 2017, approximately half of the budget was used for workshops and the other half for the purchasing of incentives. No additional major capital expenditures have been made. Instead, DART has used existing resources to provide programming. Several workshops have been provided at no cost to DART through leveraging connections with wellness organizations and professionals. 6.5.8 Qualitative Program Benefits Behavioral and cultural shifts have occurred both within the management of DART and within the employee community. A new leadership approach, brought about by a transition in management positions, has been instrumental in changing the environment and focus of the agency. DART appointed a new chief operating officer in October 2015 and a new chief human resources officer in December 2016 (DART n.d.-a). Within the employee community, the inclusion of influential individuals on the wellness committee has been an important component to foster a sense of ownership of the program. There is a focus on the personal participation and commitment to life changes of the committee members. The administration has taken the feedback received at the monthly wellness committee meetings and used it to structure the program and increased the budget for next year of the program based on the input of the wellness committee (McMahon, personal communication, 2018). Participation in the HRA was approximately 20% before the start of the wellness program because of workforce resistance to the biometrics screening, which was a requirement for being enrolled in the agency health insurance plan. Following the start of the program in October 2017, 100% of the agencyâs employees participated in the subsequent HRA, which occurred the next month. DART recognized that a lack of clarity about whether the HRA was a required part of the bioscreening contributed to the initially low participation rate. Among the employees, some fear also had existed about what the results of the HRA would be used for. The start of the wellness program prompted more discussion with union leadership and with the employees in general, which led to a shift in perception and an increase in engagement, which was the most important and effective change (McMahon, personal communication, 2018). Despite these successes, management acknowledges that other elements of the wellness program have not reached all employees. Although events were held at different times of day and days of the week in an attempt to boost participation, scheduling remained an issue. The employees who did attend came to many of the events. The small percentage of employees who were very active in the program got the most benefit. From the perspective of the union, the program was beneficial in raising awareness of health issues and there was a general sentiment that it was a good idea. Most employees lacked a will- ingness to participate long-term in the program, however. Frontline employees were asked to attend program events in their free time while administrative employees were often on the clock during events; this created some resentment among frontline employees and exacerbated

78 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line problems of participation. Participation increased when incentives were offered, but the effect of the incentives dwindled over time. Issues related to participation were difficult to address given the varying shifts of frontline workers, particularly operators. The types of shifts that employees worked had an impact on how they engaged with the wellness program. Operators were more likely to participate in the scheduled events (presumably because these events fit into their breaks between shifts), whereas maintainers/mechanics used the onsite gym at a higher rate. After running for 9 months, the wellness program discontinued. Due to several agency staff members leaving who had been instrumental in the vision for the program, the committee was dissolved and no more regular events were scheduled. 6.5.9 Reported Metrics Participation data were collected and recorded for each event (McMahon, personal commu- nication, 2018). The goal for participation in the first year of the wellness program was 30% of employees. Actual participation, measured as having attended at least one activity/workshop, was around 42% of employees. Participation in the HRA and biometrics screenings increased from 20% before the start of the program to 100% in the month following the start of the program (McMahon, personal communication, 2018). Although the program was too brief to be able to measure changes in other metrics, such as workersâ compensation claims and absenteeism, program staff has continued to collect data to help assess the effectiveness of the program. 6.5.10 Workforce Characteristics A total of 245 frontline workers (operators and maintenance) were employed with DART at the beginning of 2016, a year before the program started in 2017. Table 41 presents demo- graphic information for the total population of frontline employees and separate break downs for the operators and maintenance employees. Unlike the other case studies, information on age at the individual level was not provided by DART. Compared to some populations in the other case studies, a larger share of this workforce (84.9%) was male. As in the other agencies, the majority of maintenance workers were male. The analysis method was to examine if and how outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: those who were recorded as having participated in at least one activity Demographic Characteristic * Operator Maintenance All Count Percent Count Percent Count Percent Asian 9 4.4% 3 7.1% 12 4.9% African American 64 31.5% 13 31.0% 77 31.4% Hispanic or Latino 14 6.9% 8 19.1% 22 9.0% Two or more races 1 0.5% 1 2.4% 2 0.8% White 115 56.7% 17 40.5% 132 53.9% Female 36 17.7% 1 2.4% 37 15.1% Male 167 82.3% 41 97.6% 208 84.9% All 203 100.0% 42 100.0% 245 100.0% * Age-related information at the individual level was unavailable for this case study. Table 41. Demographics of DART frontline population, 2016.

Case Studies: Health Promotion Programs 79 and those who were recorded as having participated in no activities. The characteristics of these two groups are displayed in Table 42. The activities included a series of workshops and wellness challenges. As Table 42 demonstrates, 16 employees (out of a total of 245) were recorded by human resources as having participated in at least one activity. Many of the individuals who participated in at least one activity participated in multiple activities. This analysis did not account for marginal gains associated with participation in multiple activities. 6.5.11 The Program Over Time Figure 14 presents the average number of annual absentee hours for DART frontline employees for a 3-year period (2016â2018). Absenteeism hours were defined based on total hours of sick leave, personal leave, and unpaid leave. Figures 14, 15, 16, and 17 show absentee days over time by demographic characteristics and by job classification. A full year of information was not available for 2018, so for 2018 the full year was estimated by comparing the available months with the previous year and assuming that the difference in hours remained the same between the first and last six months of 2017 and 2018. Figure 15 presents the median annual absentee hours for race and sex. Figure 16 presents the average annual absentee hours for DART frontline employees divided by job type over the same 3-year period (2016â2018). Figure 17 presents the absentee hours over time for all employees and those that participated or did not participate in any activities. On average, employees who participated in any activities Program Participation Operator Maintenance AllCount Percent Count Percent Count Percent Did not participate 191 94.1% 38 90.5% 229 93.5% Participated in at least one activity 12 5.9% 4 9.5% 16 6.5% All 203 100.0% 42 100.0% 245 100.0% Table 42. Program participation of DART frontline population, 2016. 0 50 100 150 200 2016 2017 2018 White Female Hispanic or Latino Male Black or African American Other Grand Total Figure 14. Average annual total absentee hours of DART frontline employees by demographic characteristics, 2016â2018.

80 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 15. Median annual total absentee hours of DART frontline employees by race and sex, 2016â2018. 0 20 40 60 80 100 120 140 160 2016 2017 2018 Black or African American White Female Male Grand Total Figure 16. Average annual total absentee hours of DART frontline employees by job classification, 2016â2018. 0 20 40 60 80 100 120 140 160 180 2016 2017 2018 Maintenance Operator Grand Total Figure 17. Total absentee hours, DART frontline employees, 2016â2018. 0 20 40 60 80 100 120 140 2016 2017 2018 No Participation Participated in Activities Grand Total

Case Studies: Health Promotion Programs 81 used fewer sick days than did non-participating employees; however, because only 16 employees are recorded as participating in any activities, this is probably a case of self-selection bias. 6.5.12 Results A set of 115 observations were available to test for whether program participation had an effect on health. The principal regression model was used to examine the relationship between program participation and absentee hours (see Table 43). The model included controls for race, gender, and type of employee (mechanic or operator). The coefficient estimate of â3.9 was statistically significant at the 95% confidence level. Thus, the project team estimated parti cipation in the program resulted in a 4-hour decrease in absentee hours. Further, race was found to be statistically significant at the 95% confidence level. Specifically, if an employee was White, then absentee hours decreased by 16 hours. No other variable was statistically significant. Because the sample of workers was smallâonly 12 operators and 4 mechanics participated in at least one activityâthe results may be meaningful, but should be interpreted with caution. The results from this model demonstrate that it is possible to find an impact of a wellness program on one of the measures (absentee hours) that often is available at transit agencies. Other agencies may be able to use this approach to evaluate the effectiveness of their wellness programs. 6.6 LA Metro This case study was developed through emails and discussions with the International Union of Sheet, Metal, Air, Rail and Transportation Workers (SMART)âMetropolitan Transportation Authority (MTA) wellness manager and the vice-general chairman of SMART Local 1565. 6.6.1 Background LA Metro serves the 9.6 million residents of Los Angeles County, California, with 165 bus routes and a fleet of 2,308 buses alongside four light rail and two subway lines. Bus and rail operators at LA Metro totaled 4,397 employees in 2018. These occupations were represented by the United Transportation Union (UTU) until 2008, when the UTU merged with SMART. LA Metro also employs 2,370 mechanics, who are represented by the ATU. There are 9,817 total full-time employees at LA Metro. Together, SMART and the MTA manage a trust fund that administers benefits for bus and light rail operators. Ordinary Least Squares: Change in Hours Estimate t-Stat Intercept 38.0 3.60 Participation -3.9 -2.13 Male -5.9 -0.55 White -16.2 -2.32 Mechanic -3.5 -0.40 Observations 115.0 -- R2 0.078 -- Adjusted R2 0.046 -- Table 43. Effect of program participation on absentee hours, DART frontline employees, 2016â2017.

82 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.6.2 Program Startup and Development In 2006, LA Metro piloted a health and wellness pilot program at two locations. The agency started the pilot to produce positive effects on absenteeism and workersâ compensation claims. At the end of the pilot program in 2009, LA Metro determined that it did not have the resources to continue to fund the program long-term; however, the value of the program had been recognized and the SMART-MTA trust fund stepped in to manage a permanent program. The program was expanded to 24 locations, including all of the main facilities. 6.6.3 Work Organization/Work Environment Currently, almost 50% of operators work split shifts, with the remainder split evenly between operators who work three shifts and those who work more traditional hours. Because of the demands of their schedules, fatigue can be an issue preventing operators from attending wellness program events. This type of schedule also can be seen as a benefit, however, because operators can use their breaks between shifts as an opportunity to rest, exercise, and/or participate in wellness activities. Since 2017, SMART has worked with the University of California, Irvine, to assess the workplace and job tasks that positively and negatively impact employeesâ health and behaviors. The health program plans to use the findings from the university assessment to create program- ming to improve the overall health of employees and their families. The close attention to employees has helped uncover issues that can be resolved by influencing positive changes in corporate culture, policies, and procedures at LA Metro (e.g., schedule changes). 6.6.4 Health, Wellness, and Safety Concerns According to the SMART-MTA Wellness Program Strategic Plan 2018â2020, diabetes, hyper- tension, and cancer are targeted for disease management programs. The vice-general chairman at SMART cited diabetes, high blood pressure/hypertension, and stress as the top three health and safety issues with which the union and its members are most concerned. He shared that stress contributes to many of the health issues that operators suffer from, such as heart condi- tions and sleep apnea, which are causes for medical disqualification of operators, though the instances are low (Wormley, personal communication, 2019). 6.6.5 Program Activities/Elements The primary focus of the health and wellness program is to assist operators, but all employees, regardless of union affiliation, can participate. One program feature cited by the agency and union as leading to its success is the use of ambassadors. Ambassadors are selected from among the frontline workers to promote the wellness program. Each location has an ambassador, and large locations may have multiple ambassadors. Most locations have two wellness ambassadors from SMART (usually a main and an alternate). On specified days (called Wellness Wednesdays), the wellness ambassadors are given 8 hours of release time to engage employees in program activities. Ambassadors also are given hours of release time for offsite events, which are primarily weekend events. Compensation for ambassadorsâ time spent on wellness program duties is covered by the MTA. LA Metroâs wellness program runs year-round and features disease management and edu- cation, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Each year, eight health fairs are held at different facilities on a rotating schedule with the result that over 3 years, all locations hold a

Case Studies: Health Promotion Programs 83 health fair. Wellness activities occur mainly on Wednesdays and are scheduled to coincide with operator breaks between split shifts. The wellness program also has an incentivized weight loss program, called the Metrofit Club. The program is optional and requires a commitment of 10â12 weeks. Participants weigh in every other week with their wellness ambassador and receive assistance in their efforts through education on calculating caloric intake, recipe preparation, and basic nutrition. The program is incentivized with monetary rewards of up to $100 for losing a certain percentage of body weight. A concerted effort has been made to promote LA Metroâs wellness program. This has been done in several ways, including the presence of wellness ambassadors; union, employer, and health plan communication channels; incentives, rewards, kickoff events, challenges, and contests; a consistent theme and key messages; and mail, posters, email, newsletters, and social media marketing and testimonials. 6.6.6 Program Organization The health and wellness program is managed by a full-time coordinator. A health and wellness committee also provides input on programming and goals. The committee meets quarterly, is chaired by the wellness coordinator, and is represented equally by staff and labor members, though two unions working with LA Metro are not represented on the committee (the ATU and the Teamsters Union, which represents security guards). SMART is working toward a goal of including the Teamsters Union and the ATU on the committee, representing mechanics. Ambassadors are chosen jointly by union leadership and management. Every January, the ambassador roles and responsibilities are reviewed, and ambassadors are asked if they want to renew their contract. Training for new ambassadors occurs every quarter. 6.6.7 Program Resources Program costs, not including ambassador pay and the salary of the wellness program manager, amount to approximately $55,000 annually. Health insurance providers contribute to the budget as part of the services offered to employees in exchange for premiums; however, the insur- ance provider does not control the program fund itself. A union trust fund covers the ambas- sador pay (about $275,000 annually) and also covers the salary of the wellness program manager. 6.6.8 Qualitative Program Benefits The project teamâs analysis indicated that the pilot program produced benefits. Injury- related claims decreased at some locations, and employees reported better sleep, weight loss, and reduced stress. Participation was tracked by employee badge number and showed that 382 employees participated in some element of the program during the pilot. Since 2009, the expanded program has seen increased levels of participation. Between 2009 and 2012, long-term goals of the program were to reach 10% partici pation and limit health insurance premium rate increases to no more than 5%. Increased partici- pation in the expanded program meant that more employees accessed services covered by the health insurance provider, which led to higher premium rates. Although the increased participation was a positive step, it negatively impacted the premium; for this reason, the well- ness committee changed the goal respecting premiums to maintaining a cost âless than the Southern California healthcare trends.â Program Promotion â¢ Wellness ambassadors; â¢ Use of all communication channels (union, employer, and health plan); â¢ Incentives, rewards, kick-off events, challenges, and contests; â¢ Consistent theme, key messages; and â¢ Mail, posters, email, newsletters, social media, and testimonials.

84 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line SMART uses program data from its health insurance provider to tailor the program and counter cost trends. For example, high numbers of emergency room (ER) visits led to program education on how to avoid using the ER by scheduling appointments and going first to primary care. Results from biometrics screenings performed at the health fairs and data from LA Metro on employee metrics also are used to inform programmatic elements. Results are communicated in a newsletter for members with highlights of the changes in different measures. The program has resulted in policy changes that signify management and union willingness to work together toward the health of employees and ensure that the program receives the proper support and attention. When the program first started and the concept of well- ness ambassadors was introduced, management at LA Metro agreed to provide time off for the ambassadorsâ participation in Wellness Wednesday activities. As the program progressed, wellness ambassadors were given paid time for Wellness Wednesdays, and eventually were given paid time off for events outside of work hours, including weekend events. This shift has raised the status of wellness ambassadors and the program generally. According to the program coordinator, the employeesâ attitudes toward the program have changed from indifference to more overtly positive sentiments. Employees actively seek out elements of the program and are more willing to provide their success stories, which are published in the wellness newsletter. Union leadership expressed the view that members are genuinely excited about the program and appreciate the involvement of the union and management because it shows that both the union and management have taken a concern in the operatorsâ health. 6.6.9 Reported Metrics For this analysis, participation was defined as a person attending at least one event within a year. From 2012 through 2017, participation data from LA Metro showed generally positive trends, rising to 38% by 2014 and remaining close to that percentage in later years (Figure 18). Through the Metrofit Club, SMART has tracked the weight loss of participating employees. Figure 19 shows a peak in pounds lost in 2014, after which the amount of weight lost declined in 2015 and 2016. The drop-off may not be a negative trend, however, as the amount of weight lost in 2014 might mean that many participants had already reached or were approaching a healthy weight. Figure 20 shows the number of health club participants per year. The peak was in 2014 at 584 participants. There was a drop-off in 2016, but a slight increase in 2017 brought the number 38%37%38%38% 33% 28% 0% 5% 10% 15% 20% 25% 30% 35% 40% 201720162015201420132012 Figure 18. Participation in health program as a percentage of total LA Metro employee population, 2012â2017.

Case Studies: Health Promotion Programs 85 of participants back up to 446. The pattern seems to be fairly stable and all other years were higher than the initial year of 2012. Data from LA Metro was only provided in the aggregate, so the project team was unable to conduct regression modeling as was done with the other case studies. The information learned from this case study was based on LA Metroâs reports of employee participation in the activities and the overall weight lost by employees, but could not be correlated with outcomes such as absenteeism or controlled for race, gender, or type of position. 6.7 Summary of Case Studies The work organization and environment at each case study location was unique, and each agency faced different health, wellness, and safety challenges. Many commonalities were found across the locations, however: For example, at all five locations, the majority of bus operators worked split shifts, and some operators worked irregular schedules. The varied scheduling patterns impacted operatorsâ access to healthy food and their sleep patterns, and limited their ability to participate in certain health and wellness program activities. 6.7.1 Program Development and Work Environment The health and wellness programs examined were developed for various reasons and to meet various needs. For example, IndyGo added an onsite clinic as a way to avoid steep insurance premium increases. RTS began with a focus on physical fitness, but added more goals after several years, eventually hiring a full-time health and wellness coordinator. TARCâs 1,500 1,345 1,580 2,039 1,799 1,162 0 500 1000 1500 2000 2500 201720162015201420132012 Po un ds Figure 19. Weight lost per year (in pounds), Metrofit Club participants, 2012â2017. 446420 537 584564 305 0 100 200 300 400 500 600 700 201720162015201420132012 Figure 20. Number of Metrofit Club participants per year, 2012â2017.

86 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line initial focus was on smoking cessation, but the program was expanded to include more general wellness goals. DART encouraged employees to take advantage of all existing employee benefit programs, including a health savings account, and implemented a comprehensive wellness program for all employees. LA Metroâs program began as a pilot in two locations and expanded to 24 locations. At all the sites, at least half of the operators worked split shifts. This presented some chal- lenges for staff, including accessing healthy food choices and finding time for regular exercise. Irregular shifts also contributed to sleep deprivation. An issue emphasized at most sites by staff and union representatives was restroom access. 6.7.2 Health, Wellness, and Safety Concerns Comparing the top three health, wellness, and safety concerns expressed by management and labor representatives and examining insurance claims data, the project team found hyper- tension, musculoskeletal injuries (back and neck pain), and diabetes to be the most commonly found concerns for frontline transit workers across the locations (Table 44). Other areas of concern included sleep apnea, cardiovascular diseases (heart conditions), injuries from bus accidents, obesity, stress/fatigue, and cholesterol disorders (hyperlipidemia). Table 44 lists the top three health issues for each of the health and wellness programs discussed in the case studies and breaks down each issue by three sources: management, labor, and claims data. Not all locations provided data from all three sources. In several cases, management used analysis from insurance claims data to respond to the question about their top health, wellness, and safety concerns. At all five case study locations, labor listed diabetes as a major concernâindeed, in two of the five locations, it was the top concern. Hypertension also was named by labor in four of the five agency locations. Claims data added obesity (including hyperlipidemia) and back pain to the list of top health issues. Management, on the other hand, was more concerned with musculoskeletal injuries, weight management/cardiovascular health, and vehicular accidents. Figure 21 graphs the information presented in Table 44. Again, the most commonly mentioned issue was hypertension, followed by diabetes and musculoskeletal injuries. Areas with only one mention were included in the âOtherâ category. The distribution of concerns in Figure 21 Program Constituent Priority of Health/Safety Concern Primary Secondary Tertiary IndyGo Management Musculoskeletal injuries Slips, trips, and falls Vehicle accidents Labor Diabetes Sleep apnea Hypertension Claims data Obesity Hypertension Diabetes RTS Labor Sleep apnea Diabetes HypertensionClaims data Hypertension Cholesterol disorders Back and neck problems TARC Labor Operator assault Operator injury from accidents Breathing in harmful fumes Claims data Hypertension Hyperlipidemia Back pain DART Management Weight management Cardiovascular health Ergonomics/fatigue/stress management Labor Chronic pain from the job Hypertension Metabolic disease (e.g., diabetes) LA Metro Joint trust fund Diabetes Hypertension CancerLabor Diabetes Hypertension Stress Table 44. Comparison of top three health, wellness, and safety concerns at five case study locations.

Case Studies: Health Promotion Programs 87 broadly follows the data presented in Chapter 4 regarding the most prevalent health and safety issues for transit workers, with other key conditions also represented. Given the variations in data-supported or perceived health and wellness concerns, program design elements such as activities offered, facility needs, incentives for participation, staffing, organization of committees, and selection of champions were distinct from location to location. Chapter 7 presents process-driven strategies based on these case studies that transit systems can use to maximize program effectiveness. 6.7.3 Program Activities and Elements The programs offered various voluntary activities to employees, though it was common to provide incentives for participation. At IndyGo, participants were required to undergo a physical, health assessment, biometric screening, a minimum of four coaching sessions, and participate in a health activity to qualify for an insurance discount. Health activities might include gardening, Weight Watchers, exercise classes, walkârun groups, 5Ks, basketball tournaments, and/or financial or nutrition classes. RTS offered short workshops onsite, fresh fruit, team activities, different choices in their vending machines, blood pressure kiosks, health screenings, and a wellness center that includes a gym. TARCâs program began with a focus on smoking cessation but later expanded to provide events and programs organized around themes of interest, an annual corporate games week- end, and a fitness-oriented boot camp. The agency has offered some incentives and prizes to participants, but nothing systematic. TARC has provided its employees access to two onsite fitness centers, where they can participate in weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreens. Figure 21. Most common health, wellness, and safety concerns at five case study locations.

88 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line DARTâs program did not focus on any one aspect of health and wellness but had a different theme each month that corresponds with the interests recorded by employees in the initial survey. DART has offered two to three workshops and one to three wellness challenges every month. Rewards were given for attending workshops. LA Metro has used wellness ambassadors and provided incentives, rewards, kickoff events, challenges, and contests. The wellness program featured disease management and education, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Following a rotating schedule, eight annual fairs were held at different facilities so that, over 3 years, all locations had held a health fair. Wellness activities were scheduled to coincide with operator breaks between split shifts. The wellness program also had an incentivized weight loss program. 6.7.4 Organization Most programs were overseen by human resources departments and used third-party vendors to provide services. Several programs had full-time coordinators and volunteers (or paid employees) who served as wellness âcoordinatorsâ or âambassadors.â The funding came from a mix of operating budgets, and agencies were able to detail staff who were already employed with the agency to serve the programs. All the sites examined had a wellness committee that was staffed with a mix of management, union representatives, and frontline staff. Committees met regularly and helped determine the activities and goals of the programs. These programs worked best when there was a cooperative relationship between management and the union. The programs demonstrated a wide range of budgets and operating processes. The best-funded of the case studies was IndyGo, which staffed a clinic with two nurse practitioners, a part-time doctor, and medical assistants. During the assessed period, IndyGo operated with a budget of $500,000 per year. RTS employed one full-time wellness coordinator and funded the program through the agencyâs operating budget, using third-party vendors, spending approximately $41,000 per year. TARCâs program was funded by the agencyâs human resources office with a budget of approximately $10,000 per year, though the program received additional funds via a premium refund from their health insurance carrier. DART had a relatively low budget of approximately $5,000 annually. Dart relied on existing staff members to manage the program rather than hiring dedicated personnel. Finally, LA Metro spent approximately $55,000 annually, not including the salary for the program coordinator. The health insurance provider contributed to the program budget through a negotiated premium arrangement, though the fund itself was not controlled by the health insurance provider. A union trust fund covered the ambassadorsâ pay and the salary of the wellness program manager. 6.7.5 Workforce Characteristics Overall, a racial and gender divide was evident based on job roles. The majority of operators were male, but some gender diversity could be found, with one site having a male population of âonlyâ 52.3% (see Table 45). Maintenance workers were overwhelmingly male, with no site lower than 93%. At all sites, at least three-quarters of maintenance employees were White. The demographics of the populations that are eligible or participate in the wellness programs can help agencies decide on how to focus their activities and how to market them effectively. Figure 22 shows the annual total average absentee hours for each of the case study sites. A great deal of variability can be seen across the agencies, which leads to the conclusion that each must be considered in a local context. Absenteeism seems to be a much greater issue in

Case Studies: Health Promotion Programs 89 some places than others: DART, in particular, experienced such high rates that it is possible to suspect some data discrepancy may explain it, though our discussions with the agency did not suggest this. IndyGo experienced a fairly steady rise in absenteeism beginning in 2014, which might be attributable to a structural change. RTS and TARC have more level numbers, but also seem to have experienced slight rises in absentee hours. This issue is one that agencies will want to continue to monitor. Although absenteeism seems like a good outcome variable for evaluation, it is open to many potential causes that a wellness program will not be able to address. 6.7.6 Conclusions The newly available primary source employee data from this study has provided informa- tive descriptive statistics and statistical results. Details have been included about how pro- grams were developed, the organizing process, and the services and activities offered by each site. Where possible, the project team gathered individual-level data on workforce character- istics, participation rates, and program metrics. The metrics gathered included claims data, data on specific disorders, prescription claims, absentee hours, and workersâ compensation claims. These data have provided a big picture understanding of workforce patternsâand how variable they are. The data examined in this chapter adds to findings from the literature review on the effective- ness of health promotion programs. Although these studies may not have produced measurable Agency Operator MaintenanceBlack Male Age a Black Male Age a IndyGo 85.7% 60.9% 54.7 24.1% 93.1% 58.5 RTS 39.3% 74.9% 56.8 33.3% 98.1% 55.6 TARC 80.6% 52.3% 56.8 3.6% 98.2% 55.6 DART 31.5% 82.3% Unavailable 31.0% 97.6% Unavailable LA Metro b Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable a All ages are averages. b LA Metro did not share individual-level data. Table 45. Summary of wellness program participant characteristics. Figure 22. Comparison of average annual absentee hours across sites. 0 20 40 60 80 100 120 140 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 INDY GO RTS TARC DART

90 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line effects that translate to quantifiable cost savings for agencies, the absence of concrete statistical evidence does not mean the cases lack substantial value. The data that was collected and analyzed adds a host of new information on employee patterns of absence/sick leave and how it relates to participation in health and wellness programs among different segments of the employee population. The project team could not identify a direct relationship between the programs offered and the outcomes examined, but the process followed offers a good way to understand how agencies may undertake such evaluations regarding their own programs. Having clear data available on participants, what programs they have participated in, and for how long, could make future research easier to undertake and interpret.

Transit workers experience more health and safety problems than the general workforce, primarily as a result of a combination of physical demands, environmental factors, and stresses related to their jobs.

The TRB Transit Cooperative Research Program's TCRP Research Report 217: Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line focuses on the prevalence of these conditions, costs associated with these conditions, and statistical analysis of data on participation in and the results of health and wellness promotion programs.

Supplemental files to the report include a PowerPoint of the final briefing on the research and the Executive Summary .

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Research article
Open access
Published: 25 May 2012

The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation

Divya Rajaraman 1 ,
Sandra Travasso 2 ,
Achira Chatterjee 2 ,
Bhargav Bhat 2 ,
Gracy Andrew 2 ,
Suraj Parab 2 &
Vikram Patel 2 , 3

BMC Health Services Research volume 12 , Article number: 127 ( 2012 ) Cite this article

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Studies in resource-limited settings have shown that there are constraints to the use of teachers, peers or health professionals to deliver school health promotion interventions. School health programmes delivered by trained lay health counsellors could offer a cost-effective alternative. This paper presents a case study of a multi-component school health promotion intervention in India that was delivered by lay school health counsellors, who possessed neither formal educational nor health provider qualifications.

The intervention was based on the WHO’s Health Promoting Schools framework, and included health screening camps; an anonymous letter box for student questions and complaints; classroom-based life skills training; and, individual psycho-social and academic counselling for students. The intervention was delivered by a lay school health counsellor who had attained a minimum of a high school education. The counsellor was trained over four weeks and received structured supervision from health professionals working for the implementing NGO. The evaluation design was a mixed methods case study. Quantitative process indicators were collected to assess the extent to which the programme was delivered as planned (feasibility), the uptake of services (acceptability), and the number of students who received corrective health treatment (evidence of impact). Semi-structured interviews were conducted over two years with 108 stakeholders, and were analysed to identify barriers and facilitators for the programme (feasibility), evaluate acceptability, and gather evidence of positive or negative effects of the programme.

Feasibility was established by the high reported coverage of all the targeted activities by the school health counsellor. Acceptability was indicated by a growing number of submissions to the students’ anonymous letter-box; more students self-referring for counselling services over time; and, the perceived need for the programme, as expressed by principals, parents and students. A minority of teachers complained that there was inadequate information sharing about the programme and mentioned reservations about the capacities of the lay health counsellor. Preliminary evidence of the positive effects of the programme included the correction of vision problems detected in health screening camps, and qualitative evidence of changes in health-related knowledge and behaviour of students.

A task-shifting approach of delegating school health promotion activities to lay school health counsellors rather than education or health professionals shows promise of effectiveness as a scalable model for promoting the health and well being of school based adolescents in resource constrained settings.

Peer Review reports

Approximately a third of the Indian population is between the ages of 10–24 years [ 1 ]. Young people in India face a range of sexual and reproductive health risks such as HIV infection, early marriage and sexual abuse [ 2 ]. They are also affected by the double burden of under and over-nutrition [ 3 , 4 ], while coping with social, academic and mental health concerns [ 5 ]. Since the World Health Organization (WHO) Ottawa Charter of 1986, there has been increasing recognition of the need to promote health in the settings in which people live, learn, work and love [ 6 – 8 ]. Given the amount of time young people spend in formal education, schools are an ideal setting for promoting adolescent health [ 9 , 10 ]. The government of India, in its National Health Policy, has identified schools as a key location for improving the health of young people, through provision of information and health services [ 11 ]. The WHO Health Promoting Schools (HPS) model was endorsed by a Government of India committee in 2007 [ 12 ]. Some of the distinguishing features of a HPS are that it involves all significant concerned stakeholders; strives to provide a safe and healthy environment; promotes skills based health education; promotes access to health services; promotes adoption of health promoting policies & practices; and, ultimately strives to improve the health of the community [ 9 ]. Health promoting schools go beyond the conventional model of simply providing information about health; they aim to create a setting where the school environment, policies, institutional culture and linkages with external partners all contribute to improving the health and education outcomes of students. This approach is thought to be particularly conducive for empowerment and health literacy within a society [ 13 ].

Across India, government and NGOs are working in partnership to develop, implement and evaluate different models for school health promotion [ 14 – 19 ]. However, the evidence for their acceptability, feasibility and effectiveness is limited [ 2 ]. An ongoing debate for the design of school health programmes is the choice of human resource delivery model. A range of studies in different parts of the world have attempted to assess whether teacher or peer led models of health education are more effective. To date the evidence remains inconclusive [ 20 ]. The sustainability of either of these models may be questionable in resource constrained settings, given competing pressures of time for both teachers and peers, and a severe global shortage of qualified school teachers [ 21 ].

In the context of the global shortage of human resources for health, the World Health Organization has endorsed the concept of ‘task-shifting’, which involves the delegation of tasks and responsibilities from more specialised to less specialised cadres; successful implementation of task-shifting requires clearly defined roles, as well as robust systems of supervision and referral [ 22 ]. In settings where adolescent school health promotion is constrained by a shortage of teachers, health educators and qualified counsellors to deliver programmes, a lay school health counsellor could provide a scalable option for implementing health promotion in schools. This paper reports on a case study of a lay school health counsellor led health promotion programme in secondary schools in Goa, India. The aim of the case study was to evaluate the programme’s potential for scale up, in terms of it feasibility, acceptability, and preliminary evidence of impact.

Study setting

The study was carried out in Goa, a state on the west coast of India. Goa has a population of about 1.45 million, and a higher level of urbanization and school enrolment than the Indian national average. The programme was set in ten government aided secondary schools in rural and peri-urban areas which are likely to be representative of schools serving low income populations in urban and semi-urban areas of India.

The intervention

The S chool H e A lth P romotion and E mpowerment (SHAPE) programme was developed by a Goa-based NGO, Sangath ( http://www.sangath.com ), building on previous experience in adolescent mental and sexual health interventions that were led by teachers and peers [ 23 ], and a pilot school health promotion project delivered by lay School Health Counsellors (SHCs) in four schools in Goa in 2008–9. The intervention, which was targeted to male and female students from 5 th to 12 th grades in the age range of 9–17 years old, was aligned with the HPS approach. The activities included annual visual assessment and nutritional screening camps for all students; an anonymous letter box for students to voice their questions and concerns (Speak Out Box); classroom-based life skills training and individual counselling for students. A description of the intervention components is provided in Table 1 .

The intervention was implemented by female SHCs between 2009 and 2011. Every school had one full-time SHC, who was nominated by the participating school, but paid by the NGO. Some of the SHCs were alumni of the schools in which they were placed. Before the start of the intervention, the SHCs received 40 days of training from the implementing NGO to acquire the knowledge and skills considered necessary to fulfil their roles. Their responsibilities included: coordinating with stakeholders and convening meetings; conducting nutritional and visual assessments of all students; reviewing and acting upon Speak Out Box submissions; delivering the classroom based life skills programme; providing individual counselling to students; and, record-keeping. In the first year of the intervention, the SHCs received supervision from a clinical supervisor (trained clinical psychologist) in weekly group meetings at the NGO office and bi-monthly on-site school visits. In the second year of the programme, the supervision was scaled down to bi-monthly group meetings at the NGO office and monthly school supervisory visits. The individual counselling was conducted jointly by a clinical supervisor and the SHC in the first year of the intervention, as part of on the job training. In the second year, the SHCs were encouraged to counsel students on their own, only referring difficult cases to the clinical supervisor.

Each school had a School Health Promotion Advisory Board (SHPAB), which included the school principal, the SHC, one teacher, two parents, and a male and female student. The SHPAB was scheduled to meet once in three months, and its purpose was to tailor the programme for the school’s needs, provide input on all activities, monitor progress, and relay information about the programme and targets to the stakeholder groups.

The intervention also included facilitating the development and implementation of healthy school policies (on bullying and violence, substance use, and inclusive education). This activity involved both the SHC and programme staff from the NGO, and it is not described in this paper.

Study design

A mixed methods case study approach was used for this evaluation, with the unit of analysis being the pilot school health promotion programme. The case study design is a methodology that allows for a phenomenon to be described and interpreted in its context, using multiple of data sources [ 24 ]. It is a particularly versatile approach, allowing for variety in the selection of the unit of analysis and a range of methods [ 25 ]. The case study is considered useful in health sciences research, as it provides flexibility and rigour for developing and testing theory, evaluating programmes, and developing interventions [ 26 ]. The aims of this study were to assess the feasibility and acceptability of the intervention and gather preliminary evidence of impact [Table 2 . The study aimed to generate evidence for whether the pilot intervention showed potential for further evaluation of effectiveness and the descriptive approach of the study is consistent with the formative and piloting research phases of the UK MRC framework for complex interventions [ 27 ]. Nine schools were evaluated over a two year period; in one school, the intervention started only in the second year.

Quantitative programme monitoring data

Programme monitoring data were collected over two years to assess whether the programme was delivered as planned (indicating feasibility), to measure the uptake of services (indicating acceptability), and to determine the number of students who received treatment following health screening camps (evidence of impact). The quantitative process indicators included the number of activities delivered, the number of participants reached by different activities, and the number of health or other problems identified and rectified through the various activities. These data were recorded by the SHCs in their daily monitoring registers, and were reviewed for accuracy and completeness on a weekly basis by a research officer. The data were subsequently entered into an electronic database, and cleaned and analysed in SPSS [ 28 ]. The coverage of the programme was estimated as the proportion of the planned activities that was delivered, as per the intervention targets set at the beginning of the year by the programme development team.

Qualitative semi-structured interviews

The purpose of the semi-structured interviews was to capture the range of experiences and opinions relating to the programme in its first and second year, in order to identify barriers and facilitators (feasibility); assess perceived utility of the various programme activities (acceptability); and, gather evidence of positive or negative effects of programme activities (impact). Using a quota sampling strategy, a total of 108 semi-structured interviews were conducted with SHCs, programme coordinators and clinical supervisors from the implementing NGO, school principals, teachers, and students. All programme staff and school principals were invited to participate. As a large number of teachers and students were reached by the programme, only a subset in these groups were interviewed; in each school, one teacher and a male and female student were selected from the SHPAB (school advisory board), and a second teacher was randomly selected from the teachers’ list for inclusion into the study. Students were randomly selected, after stratifying for school, gender, and utilization of the counselling service. Random sampling was used in order to avoid the bias of best or worst cases being nominated for interview by principals or SHCs. The large number of interviews helped to ensure that the range of experiences and opinions was captured across schools and stakeholder groups. The details of the semi-structured interview sample are shown in Table 3 .

In the first year of the programme, semi-structured interviews were conducted in all the 9 programme schools at the end of the year. In the second year, interviews were conducted in a sub-sample of 4 schools. Semi-structured interviews were conducted by three independent evaluators who were trained and supervised by experienced qualitative researchers. Interviews were conducted in Konkani (the local language) and/or English, depending on the preference of the interviewee. The research protocol received approval from the Sangath institutional ethics review board. Written informed consent was obtained from all participants, and parental consent was taken from parents of the students.

The semi-structured interviews included sections for each of the programme activities, the school health counsellor as an agent of delivery, and the overall programme. Interview guides were tailored for each type of stakeholder, probing for experiences and opinions in each section. Interviews were translated and transcribed for analysis, and Atlas-Ti was used for initial data coding [ 29 ]. A framework analysis was conducted: codes were applied for each of the programme activities, the SHC as an agent of delivery and the overall programme, and for the themes of acceptability (‘things liked’, ‘things not liked’), feasibility (‘feasible’, ‘not feasible’, ‘barriers’, ‘facilitators’), impact (‘positive effects’, ‘negative effects’), and suggestions for improvement. An initial set of transcripts was double coded to ensure consistency in applying the codes. The data were synthesised thematically in spread-sheets for each programme activity, and common themes and illustrative examples were identified.

The results are presented in three sub-sections, which report quantitative programme monitoring data and qualitative data from semi-structured interviews to assess: i) feasibility; ii) acceptability; and, iii) evidence of impact.

Feasibility

The SHAPE programme was delivered in 9 schools to 2,105 students in 2009–10, and in 10 schools to 2,199 students in 2010–11. The feasibility of the programme was assessed quantitatively by the proportion of target programme activities that were delivered, and qualitatively in terms of the barriers and facilitators identified by stakeholders. The proportion of target activities delivered in the first year was high, and increased in the second year despite reduced supervision of the SHCs (Table 4 ). Over the two years, the quarterly SHPAB meetings were held in all schools as scheduled, the visual assessment and health camps were held in all schools as per target, and the completion of the life skills programme increased from 86.6% to 92.2%. The number of students who accessed counselling increased marginally from 122 to 128, but the proportion of students remained steady, between 6.2-6.3% of all students.

Interviews with SHCs and programme coordinators revealed that in the first year of the intervention, almost half the SHCs did not have a regular class period and/or a classroom allocated for teaching the life skills sessions. Consequently, they had to deliver the classes either after school, or when another teacher was absent or had completed their syllabus. This improved in the second year, when only one of the school principals had not allotted a timetable slot to the life skills programme. While those SHCs who did not have a reserved period still managed to find ways to deliver most of the life skills syllabus, some of the SHCs and programme staff faced continued challenges in finding suitable space for counselling.

" “Infrastructure is the problem of the school because they don’t have proper place for their own classes so we cannot demand for a class or place.” "

Female Clinical Supervisor 1, 2010–11

A supportive and enthusiastic school management team was identified by programme coordinators as the most important facilitator, as this could reduce the burden of organisation and motivation carried by the SHC, and improve the participation of all school members in the programme activities.

" “Actually some schools gave us a class and some schools did not. Some schools talked about after class. Some few schools gave us the library period or [physical education] period. You know, I think this was a lot determined by the principals. So I can’t say that across the board everybody gave us a class…it was a lot dependent on the principals and how important they thought the programme was.” "

Female intervention coordinator, 2010–11

Acceptability

The acceptability of the programme activities was assessed quantitatively in terms of the uptake of services offered. Increasing acceptability of the programme over the two years was indicated by the growing number of submissions to the anonymous letter box for student complaints and questions, from 220 in the first year to 770 in the second year. In 2010–11, the majority of the questions related to psycho-social issues (49.8%), followed by students’ complaints and concerns relating to school infrastructure, management and administration (36.9%).

A second indicator of acceptability was the increasing number and proportion of students who sought individual counselling on their own and returned for follow up counselling sessions in the second year. While the total number of students who accessed individual counselling was stable across the two years (just over 6% of the student population), growing acceptability was reflected in the increased number of counselling sessions (from 251 in 2009–10 to 323 in 2010–11), and the increased proportion of self-referred cases, from 8.2% in the first year to 24.2% in the second year.

A review of stakeholder perceptions and experiences of the programme provided qualitative evidence about the acceptability of the intervention activities and of the SHC as an agent of delivery. There was a high level of expressed support for most of the programme activities from principals, teachers and students. For example, the school management, teachers and the students all saw the nutritional screening and vision assessment camps as an important means of identifying and addressing common health problems amongst populations with limited access to paid health care. In the words of one student:

" “Some students cannot afford to go to doctors for these types of health check-ups. These people are doing this in our school, and that too free of cost. That is what I like the most.” " 9 th Grade Female Student, School H, 2009–10

The anonymous letter box for student questions and concerns was also considered an important outlet for students by all stakeholder groups. According to students, the factors that increased acceptability were anonymity, confidentiality and the SHCs’ efforts to address student concerns. For example:

" “I like the Speak-Out Box because students can get their problems solved without others coming to know.” " 9 th Grade Male Student, School H, 2009–10 " “What we cannot share with our friends we can write and share with [the school health counsellor], who will keep it a secret. I liked that.” (11 th grade female student)" 11 th Grade Female Student, School I, 2009–10

While all of the school management and most of the staff interviewed were supportive of the Speak-Out Box, one teacher mentioned his reservation that students might make false reports about teachers they do not like, while another teacher felt that the lay school health counsellor was not equipped to deal with the problems raised through the Speak-Out Box. This appeared to be related to students in those schools having complained about teachers’ disciplinary practices, and the feedback being escalated by the school health counsellor to the principal.

All the stakeholder groups mentioned positive attitudes towards the life skills programme, noting that it was useful and relevant. However, in 4 out of 10 schools, the reproductive and sexual health sessions were not taught because the school management felt that the topic was not appropriate. Many students spoke about enjoying the interactive and activity-based nature of the teaching. The school principals and SHCs summarised a range of factors that contributed to the success of the life skills programme: these included consultation with the principal on the syllabus; age appropriate modules; interactive sessions, and relevant materials. In the first year, several of the teachers had recommended greater use of visual aids, which was incorporated in the second year.

In the first year of the programme, the SHCs and principals spoke about challenges to the uptake of the individual counselling, such as stigmatization of the service by students and teachers’ disappointment with the results, may have been linked to unrealistic expectations of the process and outcomes. In the second year, teachers were sensitized by the SHCs about the purpose of counselling and the type of results to be expected, and the interviews with SHCs and teachers indicated more appropriate referrals for counselling and teacher satisfaction with the outcomes. At the same time, the SHCs noted that the students were more forthcoming about attending the counselling sessions and opening up about their problems. Principals, SHCs and the programme coordinators attributed the increased student uptake and participation to greater awareness of the benefits of counselling, and students’ growing confidence that information would be kept confidential. For example:

" “In the beginning, yes…counselling was seen as stigmatising, when teachers kept sending cases. But slowly when children started understanding that this counsellor is part of the school and they can go to her with any problem, then there was less stigma, students started coming on their own.” " Female Clinical Supervisor 3, 2010–11 " “Initially counselling was a very new concept to them and they (students) may have had some misunderstanding about the things, but now the thing is they have realized the importance of it.” " Male Principal, School E, 2010–11 " “Earlier we used to feel that the [counsellor] may tell others whatever we tell her so we were scared to speak. But because of counselling, our doubts were cleared and we got help in dealing with our problems. [Now] we know that [the counsellor] doesn’t share this information with anyone else.” " 9 th Grade Female Student, School A, 2010–11

The students’ and principals’ perceptions of the SHC as an agent of delivery were favourable. Many students talked of their ability to open up and engage with the SHC, because she was more approachable than their other teachers. For example:

" “Initially, we were not telling our problems to our teachers since they would get angry, but now we are telling our [SHC].” " 6 th Grade Male Student, School B, 2009–10

In the first year of the programme, three teachers who were interviewed mentioned that they felt that the SHC was not mature enough to deliver all of the programme activities. Several teachers also complained about a lack of information sharing about the programme; this was addressed in the second year by monthly reports to teachers by the SHCs. The SHCs reported that this had resulted in greater teacher support, which appeared to be corroborated by reduced negative feedback from teachers.

Preliminary impact of the programme was indicated quantitatively by the number of students who were identified with health problems in the nutritional screening and visual assessment camps and the number who received any follow up or treatment, and qualitatively through evidence from semi-structured interviews about the effects of the various programme activities on student health and wellbeing. The health camps were a major activity conducted by the SHCs, with all eligible students present on the day/s of the camp being screened for nutritional status and full vision. In 2009–10, and 2010–11, nutritional and visual assessment camps were conducted in all schools, with the majority of eligible students being screened. In the first year, there was some criticism from principals that the health camps had not resulted in adequate follow up, even where problems were identified. In the second year, however, there was a consensus across stakeholders that the camps were more effective, as many of the students who were identified with visual or nutritional problems received follow up as a result of the SHCs’ efforts.

In 2010–11, 1,987 students underwent visual screening. Out of these students, 443 were found to have probable refractory error and 100 were detected with probable colour blindness. These students were referred for confirmation of diagnosis and treatment; 223 of the 512 students who were referred (43.6%) visited a health care provider. One of the school teachers spoke about the benefits of the visual assessment camp:

" “After the check up, [the SHC] did the follow up and children were given spectacles, which I had not expected. It was a really good initiative to give them spectacles because most of the students in our school are poor and they may not have been able to afford to buy the spectacles.” " Female Teacher, School C, 2010–11

Out of 1,917 students who received a nutritional assessment in 2010–11, 653 (34.1%) were found to be underweight and 134 (7%) were overweight or obese. These students received dietary guidelines to be taken home and shared with their parents. A parent commented on the positive effect of the nutritional assessment on her child:

" “[My son] was under weight, [the SHC] gave us a chart in which it is written what to eat and in what quantity to eat, and my son is following this. First I used to have to force him to eat, but now after this counsellor gave him a book about what to eat…he forces me to cook all the things that are there in this book for him.” " Female Parent, School C, 2010–11

The Speak Out Box was a school-wide intervention that resulted in action on a range of issues. The submissions could be anonymous and were reviewed on a weekly basis by the SHC who took the issues up with the school management where appropriate. In several schools, problems in the health environment were raised. The SHCs and principals related several instances in which the school management had acted in response to student complaints: for example, fans and drinking water filters were installed, furniture was fixed, and regular cleaning of common facilities was enforced in some schools. Other relevant Speak Out Box issues that were addressed by the school included two cases of teachers’ extreme disciplining practices and many cases of student bullying. Anti-bullying workshops/sessions were held in all schools for the management and the students. Questions about reproductive and sexual health and life skills were frequently raised through the Speak Out Box, and were addressed by the SHC in classroom based life skills sessions.

Teachers, students and parents mentioned a range of positive effects of the life skills educational sessions. One teacher discussed substance use amongst students:

" “Earlier some students used to [chew tobacco], which is no longer happening, and also gambling was there before, but this year we have not found any students with such practices…They are aware of the consequences.” " Female Teacher, School A, 2010–11

Behavioural improvements were also noted by some parents. For example:

" “There has been a lot of effect on the children, earlier they would not give up their places on the bus for people to sit. Now they get up and give their seats, especially for elders. Earlier my daughter would not listen and used to back answer me, but now there is lot of improvement in her, she behaves well. Ever since [the SHC] spoke to her, she has not back answered me.” " Female Parent, School A, 2010–11

Students from across the schools and grades mentioned that they were using the knowledge and skills learned in the classroom programme in their daily lives. This included adopting healthy eating habits (for example, reduction in consumption of aerated beverages), being more respectful to elders and more civil to peers (i.e. not bullying), avoiding abusive language, changing attitudes towards education, becoming more aware of personal safety and safety in the community, managing anger better, improving personal hygiene, and understanding the physiological changes associated with adolescence. Additionally, many students said that they had benefited from the study skills sessions, and were following the tips for concentration, memorisation and making a study timetable. In some cases, this had led to tangible improvements in academic outcomes. For example:

" “[the SHC] used to tell us what should be done in the exams and all so I followed that and I passed in many papers. First I had failed in two papers which I used to find difficult, but now I passed.” " 6 th Grade Male Student, School F, 2009–10

Finally, all groups of stakeholders recounted examples of the positive impact of individual counselling on students. In the first year, the SHCs complained about many inappropriate referrals by teachers who were not able to discipline their classes, as counselling could not be a substitute for better classroom disciplining practices. This was less of a concern in the second year, with teachers’ and students’ increased awareness about the goals of counselling and a higher proportion of self-referred cases. SHCs, students, and teachers spoke of instances where SHCs, sometimes supported by the clinical psychologists, were able to help students to cope with and/or solve their problems. These included cases of harassment and abuse, domestic violence, educational difficulties, defiant behaviour, bullying, and relationship issues. For example:

" “I opened up my secret to (the SHC), which I had never done before, not even at home. She helped me to solve it and now I am fine. Now everyone is good to me they all smile at me or speak to me. I liked it.” " 7 th Grade Female Student, School A, 2010–2011 " “I was a repeater in the 9 th standard. [The SHC] taught me study skills and gave me a time table in writing so I followed that time table and I passed and now I am in 10 th standard.” " 10 th Grade Male Student, School H, 2009–10 " “[One] child was involved with a boy. Only child of the parents and she used to be very disturbed in the class also and the counsellor did help her. And this child has really come out of the problem and she has assured that she will take care of herself and her studies at this moment and not be disturbed with all this.” " Female Principal, School C, 2010–11 " “My younger son was very short tempered, they spoke to him. That anger he had learned from me, because I used to get angry very quickly and he is just like me. Now my son is under control, they explained to him how to control his anger.” " Female Parent, School C, 2010–11 " “There used to be complaints about my son from all teachers in all classes. Now after counselling there are no complaints about him from teachers.” " Male Parent, School E, 2010–11

While there were many examples of success in individual counselling, clinical supervisors and SHCs identified some constraining factors which could limit its effectiveness, including the absence of a specific time for counselling in some schools, teachers’ stigmatising attitudes, and the limited capacities of SHCs to deal with serious cases. At the end of the second year, one of the three clinical supervisors mentioned some reservations about the SHC capacities to undertake individual counselling for difficult cases. The other two clinical supervisors reported a substantial improvement in the counselling skills of the SHCs and their ability to handle cases independently, and felt that the supervision and joint case consultation had been an effective training mechanism for the majority of cases seen. The intervention coordinator noted that all the counsellors were able to deal with cases relating to academic concerns (study skills, exam anxiety, detection of learning disorders, and career counselling); with psychosocial issues such as bullying and disability; and, with physiological concerns such as nutrition. A few SHCs continued to seek support for dealing with cases related to RSH, relationships, and suicidal ideation. Clinical psychologists mentioned that it would be important to provide on-going supervision/training for SHCs for continued skills development, as well as to ensure clearly defined referral pathways for students who need support from certified professionals.

We report on the development of a lay counsellor delivered multi-component Health Promoting Schools intervention in 10 schools in Goa. We observed that a high coverage of planned activities was achieved over the first two years. Despite reduced supervision of the school health counsellors (SHCs) from the first to the second year of the intervention, the coverage (proportion of target delivered) of programme activities increased. The activity in which the SHCs appear to require the most supervision was individual counselling; but even for this component, the numbers of adolescents counselled remained stable, self-referrals grew and follow-up sessions increased. An increasing proportion of sessions were carried out by the SHC without supervision in the second year of the programme.

Several changes were made in the second year of the intervention in response to feedback from the mid-term evaluation, including modifications in the classroom module content and mode of delivery; provision of regular information to teachers about the activities; ensuring a classroom and teaching period for the life skills session; and, securing a quiet and comfortable space for individual counselling. Overall acceptability of the activities in both years was indicated by the high uptake of services. Additionally, there was widespread agreement amongst stakeholders of the need for the programme in order to improve the health, wellbeing, and academic outcomes of students. Only one out of the ten principals was not fully cooperative, and a minority of teachers expressed persisting misconceptions about the role of the counsellor and a lack of sensitivity towards adolescents who were accessing the individual counselling service. The impact of the intervention was indicated quantitatively by the substantial number of students who were identified with and treated for nutritional or visual problems. There was also strong qualitative evidence of changes in the school environment as a result of the Speak-Out Box; in knowledge and behaviour of students as a result of life skills sessions; and, in academic, social, and mental health outcomes of students who accessed individual counselling.

We identified two other robust evaluations of school health programmes in India, both of which have yielded promising results. One teacher and peer-delivered intervention to reduce tobacco use found that students who received a school and family based intervention were significantly less likely than students in the control group to have used or have intentions to use tobacco [ 30 ]. The second, a Health Promoting Schools intervention delivered by health care providers in rural India, reported significant improvements in the nutritional status and personal hygiene of students, with associated reductions in hygiene related health problems [ 16 ]. School health promotion programmes in India have generally been developed for delivery by teachers, health care providers, or peers, partly because this is perceived as a low cost option. However, these programmes can compete with teachers’ or health care providers’ other time commitments. Peer education programmes contend with a constantly shifting population of student peer educators; thus, the sustainability and, consequently, effectiveness, of these delivery models may be limited [ 31 ]. The scalability of programmes delivered by dedicated teachers or health professionals in India is likely to be constrained by the limited number of such professionals in the country and their salary costs.

A lay health counsellor presents a potentially sustainable and scalable alternative approach for school health promotion. There are, however, no previous published studies from India or other Low or Middle Income Countries of process evaluations of multi-component school health interventions delivered by lay health workers. Formative and piloting research that incorporates mixed methods is widely recognised as critical for understanding the pathways to effectiveness of school health interventions [ 32 , 33 ]. Much of the literature in this field is drawn from high income settings, including the United Kingdom, the United States, Europe, Australia and New Zealand [ 34 – 37 ] and our study is one of the few from a developing country describing the process of development of a school based health intervention and of task-shifting the delivery of health promotion activities to a lay health counsellor.

Limitations of the study

There are some limitations to the study design. First, the intervention was conducted in government aided schools in only one state of India, and the school environment may not be generalizable across all school types and states; however, the findings may be extrapolated, with appropriate caution, to government schools in other urban and peri-urban settings, as they share similar socio-economic characteristics as Goa. Second, despite a reduction in the intensity of supervision from the first to second year of the programme, the NGO played an important monitoring role; this level of supervision may not be feasible or affordable in a scaled up programme, and could influence the quality of delivery. Third, as this was a case study and did not include a control group or statistically powered study with quantitative outcome measures, our ability to draw inferences about the effectiveness of the intervention in changing students’ knowledge or academic/health outcomes is limited. In fact, this study was designed in the context of the formative and piloting stages of the development of a complex intervention [ 38 ]. The primary aim was to assess whether the model of health promotion and the method of delivery was acceptable, feasible and showed promise of effectiveness. Thus, this study reports the first stage of evidence generation, with a focus on development, refinement and feasibility testing, which may lead to further quantitative testing of the effectiveness of the intervention.

The feasibility, acceptability and preliminary evidence indicative of impact of the lay school health counsellor delivered HPS programme suggest that this could be a promising model for definitive evaluation, and for subsequent scaling up of school health promotion, particularly where qualified teachers and health professionals are in short supply. The encouraging findings of this study warrant further research to generate evidence of the effectiveness and cost-effectiveness of different human resource delivery models for health promotion interventions in schools, comparing the SHC led intervention described in this paper with traditional models, such as teacher, peer, and psychologist led delivery. Such information would be critically important to influence wider programme and policy decisions about school health promotion in India, and in other resource limited settings.

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Acknowledgements

We would like to acknowledge the current SHAPE programme coordinators, Prachi Khanderparkar and Luiza Lobo, and the School Health Counsellors for facilitating the monitoring and evaluation of the intervention. We would also like to thank all the programme stakeholders who agreed to share their experiences and opinions with us. The SHAPE intervention in schools in Goa was funded by the Dempo Mining Corporation and the John D. and Catherine T. MacArthur Foundation. The evaluation was funded by the John D. and Catherine T. MacArthur Foundation. VP is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science.

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Sandra Travasso, Achira Chatterjee, Bhargav Bhat, Gracy Andrew, Suraj Parab & Vikram Patel

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DR contributed in the design of the evaluation framework, database development, data analysis, and drafting the manuscript. ST contributed in the design of the evaluation framework, database development, data collection, data quality monitoring, data analysis, and review of the manuscript. AC contributed in the design of the intervention and the evaluation framework, and review of the manuscript. BB contributed in the design of the evaluation framework, database development, data collection, data analysis, and review of the manuscript. GA contributed in the design of the evaluation framework, data analysis, and review of the manuscript. SP contributed in database development, data collection, data quality monitoring, data entry and data analysis, and review of the manuscript. VP contributed in the design of the intervention and the evaluation framework, database development, data analysis, and drafting the final manuscript. All authors read and approved the Final manuscript.

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Rajaraman, D., Travasso, S., Chatterjee, A. et al. The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation. BMC Health Serv Res 12 , 127 (2012). https://doi.org/10.1186/1472-6963-12-127

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Dissemination and Implementation of School-Based Health Promotion Programs: A Descriptive Comparison of Case Studies in Nicaragua and the Dominican Republic

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Jonathan Pettigrew ORCID: orcid.org/0000-0001-7938-784X 1 ,
Heidi Luft ORCID: orcid.org/0000-0002-5926-9050 2 ,
Maria Castillo 3 &
Julio A. Canario Guzmán ORCID: orcid.org/0000-0003-2947-4165 4

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Dissemination and implementation (D&I) sciences, largely developed in clinical settings located in the Global North, have much to offer and also to learn from school settings in the Global South. In this paper, we use the RE-AIM (Reach, Effectiveness, Adaptation, Implementation, Maintenance) framework to guide a descriptive comparison of D&I research conducted with school-based health promotion programs in Nicaragua and the Dominican Republic. Experiences and reflections were gathered from and synthesized by members of our international research team, composed of interdisciplinary practitioners and researchers focused on behavioral health in the Latin America and Caribbean (LAC) region. Through transparent sharing of our challenges and successes, we provide guidance that can facilitate greater quantity and quality of implementation research conducted in these understudied settings, which is critical for the advancement of D&I sciences.

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Adapting a Compilation of Implementation Strategies to Advance School-Based Implementation Research and Practice

Clayton R. Cook, Aaron R. Lyon, … Byron J. Powell

Is Implementation Fidelity Important? A Systematic Review on School-Based Mental Health Programs

Rodrigo Rojas-Andrade & Loreto Leiva Bahamondes

Implementing Effective Educational Practices at Scales of Social Importance

Robert H. Horner, George Sugai & Dean L. Fixsen

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The Case Comparison Procedures reports the methods used to describe and compare case studies; no datasets were generated or analysed for this study.

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Acknowledgements

We are grateful for the hundreds of school directors, teachers, staff, and volunteers who participated with us to develop, adapt, implement, and evaluate school-based programs. Your dedication to students and your community inspires us!

Our reflections emerge from intervention and research projects funded by various agencies. The project in Nicaragua was supported in part by grants from the International Narcotics and Law Enforcement Affairs Bureau: S-INLEC-13-GR-1012 to the University of Tennessee and S-INLEC-16-GR-1005 to Arizona State University (Jonathan Pettigrew, Principal Investigator). The work in the Dominican Republic was funded in part by Grant Number 11436-DR from the U.S. Department of State Fulbright U.S. Scholar Program, the University of Wisconsin-Milwaukee College of Nursing (Heidi Luft, Principal Investigator), and Institute for Translational Sciences at the University of Texas Medical Branch, supported in part by the Clinical and Translational Science Award (UL1 TR001439) from the National Center for Advancing Translational Science at the National Institutes of Health (NIH). The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the United States Department of State or the NIH.

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Pettigrew, J., Luft, H., Castillo, M. et al. Dissemination and Implementation of School-Based Health Promotion Programs: A Descriptive Comparison of Case Studies in Nicaragua and the Dominican Republic. Glob Implement Res Appl 3 , 112–128 (2023). https://doi.org/10.1007/s43477-023-00079-2

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Ex-assistant principal charged with child neglect in case of boy who shot teacher

The Associated Press

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023. Denise Lavoie/AP hide caption

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023.

NEWPORT NEWS, Va. — A former assistant principal at a Virginia elementary school has been charged with felony child neglect more than a year after a 6-year-old boy brought a gun to class and shot his first-grade teacher .

A special grand jury in Newport News found that Ebony Parker showed a reckless disregard for the lives of Richneck Elementary School students on Jan. 6, 2023, according to indictments unsealed Tuesday.

Parker and other school officials already face a $40 million negligence lawsuit from the teacher who was shot, Abby Zwerner. She accuses Parker and others of ignoring multiple warnings the boy had a gun and was in a "violent mood" the day of the shooting.

Criminal charges against school officials following a school shootings are quite rare, experts say. Parker, 39, faces eight felony counts, each of which is punishable by up to five years in prison.

The Associated Press left a message seeking comment Tuesday with Parker's attorney, Curtis Rogers.

Shots - Health News

'say something' tip line in schools flags gun violence threats, study finds.

Court documents filed Tuesday reveal little about the criminal case against Parker, listing only the counts and a description of the felony charge. It alleges that Parker "did commit a willful act or omission in the care of such students, in a manner so gross, wanton and culpable as to show a reckless disregard for human life."

Newport News police have said the student who shot Zwerner retrieved his mother's handgun from atop a dresser at home and brought the weapon to school concealed in a backpack.

Zwerner's lawsuit describes a series of warnings that school employees gave administrators before the shooting. The lawsuit said those warnings began with Zwerner telling Parker that the boy "was in a violent mood," had threatened to beat up a kindergartener and stared down a security officer in the lunchroom.

The lawsuit alleges that Parker "had no response, refusing even to look up" when Zwerner expressed her concerns.

When concerns were raised that the child may have transferred the gun from his backpack to his pocket, Parker said his "pockets were too small to hold a handgun and did nothing," the lawsuit states.

Architecture

With gun control far from sight, schools redesign for student safety.

A guidance counselor also asked Parker for permission to search the boy, but Parker forbade him, "and stated that John Doe's mother would be arriving soon to pick him up," the lawsuit stated.

Zwerner was sitting at a reading table in front of the class when the boy fired the gun, police said. The bullet struck Zwerner's hand and then her chest, collapsing one of her lungs. She spent nearly two weeks in the hospital and has endured multiple surgeries as well as ongoing emotional trauma, according to her lawsuit.

Parker and the lawsuit's other defendants, which include a former superintendent and the Newport News school board, have tried to block Zwerner's lawsuit.

They've argued that Zwerner's injuries fall under Virginia's workers' compensation law. Their arguments have been unsuccessful so far in blocking the litigation. A trial date for Zwerner's lawsuit is slated for January.

Prosecutors had said a year ago that they were investigating whether the "actions or omissions" of any school employees could lead to criminal charges.

What schools can (and can't) do to prevent school shootings

Howard Gwynn, the commonwealth's attorney in Newport News, said in April 2023 that he had petitioned a special grand jury to probe if any "security failures" contributed to the shooting. Gwynn wrote that an investigation could also lead to recommendations "in the hopes that such a situation never occurs again."

It is not the first school shooting to spark a criminal investigation into school officials. For instance, a former school resource officer was acquitted of all charges last year after he was accused of hiding during the Parkland school massacre in 2018.

Chuck Vergon, a professor of educational law and policy at the University of Michigan-Flint, told The AP last year that it is rare for a teacher or school official to be charged in a school shooting because allegations of criminal negligence can be difficult to prove.

More often, he said, those impacted by school shootings seek to hold school officials liable in civil court.

elementary school

Ozempic, Wegovy Won't Boost Thyroid Cancer Risk: Study

By Ernie Mundell HealthDay Reporter

WEDNESDAY, April 10, 2024 (HealthDay News) -- Wegovy, Ozempic and other drugs known as GLP-1 analogues have become wildly popular for controlling diabetes and helping folks lose weight.

There were concerns that longer term use of the drugs might raise users' odds for thyroid cancer, but a Swedish study of more than 435,000 people finds no evidence to support that notion.

“Many people take these medicines, so it is important to study potential risks associated with them,” said study lead author Björn Pasternak . He's principal researcher at the department of medicine at the Karolinska Institute in Stockholm.

“Our study covers a broad group of patients and provides strong support that GLP-1 analogues are not associated with an increased risk of thyroid cancer," he said in an institute news release .

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The findings were published April 9 in the BMJ .

In the analysis, Pasternak's team used data from a major Scandinavian database involving 145,000 people who were taking GLP-1 analogues such as liraglutide (Victoza) or semaglutide ( Ozempic ), and 290,000 people who were taking one of another class of diabetes drugs called DPP4 inhibitors.

The study found no higher odds for thyroid cancer among folks taking GLP-1 analogues compared to those on DPP4 inhibitors.

That finding was repeated when GLP-1 analogue users were compared to patients taking a third class of diabetes meds, called SGLT2 inhibitors.

Study co-author Peter Ueda , an assistant professor of medicine at the Karolinska Institute, stressed that the final verdict on GLP-1 analogues' effect on the thyroid is still to come.

“We cannot rule out that the risk of certain subtypes of thyroid cancer is increased in smaller patient groups that we could not study here, for example in people with a high congenital risk of medullary thyroid cancer who are advised against using these drugs,” Ueda said.

More information

Find out more about thyroid cancer at the American Cancer Society .

SOURCE: Karolinska Institute, news release, April 9, 2024

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Championing Health Promoting Schools: A secondary school case study
McIsaac J, Read K, Veugelers P, et al. (2017b) Culture matters: A case of school health promotion in Canada. Health Promotion International 32(2): 207-217. Crossref. ... Evaluating health promotion in schools: a case study of design, implementation and results from the Hong Kong Healthy Schools Award Scheme. Show details Hide details.
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Overview. No education system is effective unless it promotes the health and well-being of its students, staff and community. These strong links have never been more visible and compelling than in the context of the COVID-19 pandemic. A health-promoting school (HPS) approach was introduced over 25 years ago and has been promoted globally since ...
Championing Health Promoting Schools: A secondary school case study
Objective: School-based prevention interventions informed by the World Health Organization Health Promoting School (HPS) framework aim to improve the health and wellbeing of school-aged children, yet few studies describe factors influencing the successful implementation of this framework in secondary schools.
Making every school a health-promoting school
In the past year, the effect of the COVID-19 pandemic on schools has reinforced the profound links between children's health, wellbeing, and learning. In addition to deleterious effects on student engagement, learning outcomes, and educational transitions, there is growing evidence of the impact of school closures on children's and adolescents' emotional distress and mental health.1 There are ...
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References 53Pre-interview questionnaire: HPS case studies WHO and UNESCO have announced an initiative for "Making every school a health-promoting school" with development and promotion of global standards for HPS. The initiative will serve over 1.9 billion school-age children and adolescents.
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Beattie, A. (1995). The health promoting campus: a case study in project-based learning and competency profiling. In A. Edwards and P. Knight (eds), Degrees of Competence: ... Purchasing practical health promotion for the primary school: a DHA perspective. In R. Morton & J. Lloyd (eds), The Health Promoting Primary School. Chapter 2. London ...
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School health promotion is part of sustainable development and fits very well in the Sustainable Development Goals (SDG) agenda, in particular SDG 3 (Ensure healthy lives and promote well-being for all at all ages) and SDG 4 (Ensure inclusive and quality education for all and promote lifelong learning). ... Case study in Hong Kong? BMC Public ...
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Championing Health Promoting Schools: A secondary school case study from Victoria, Australia

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Article Contents

Exploring learning outcomes of school-based health promotion—a multiple case study

Theoretical framework

Research aim, focus and questions

Data generation

Program implementation

The interplay between case schools educational practices and the IVAC approach

Changes in pupils’ action competence

Action experiences

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Educational Programs for the Promotion of Health at School: A Systematic Review

María Alejandra González-Luis

Associated Data

1. Introduction

1.1. The Concept of Health

1.2. Health Promotion and Health Promoting Schools

1.3. Programs That Promote Health

2. Materials and Methods

2.1. Literature Review

2.2. Characteristics of the Included Studies

2.3. Procedure

3.1. Study Selection

3.2. Characteristics of the Included Studies

3.3. Identification of Health Promotion Programs

3.4. Effectiveness and Main Difficulties in the Development of Programs That Promote Health

4. Discussion

5. Conclusions

Author Contributions

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

ORIGINAL RESEARCH article

Introduction

Study design and school sample

Data collection

Ethical considerations

Description of schools

Description of participants

Educational context

Decision-making processes, barriers, and enablers to continuing the intervention after its official closure

Understanding of the intervention philosophy among school staff

School capabilities to continue with intervention activities

School attitudes and motivation about implementing the intervention

Education policy environment and governance structures

Overcoming barriers to continuation

Data availability statement

Ethics statement

Author contributions

Acknowledgments

Conflict of interest

Publisher’s note

Supplementary material

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The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation

Study setting

The intervention

Study design

Quantitative programme monitoring data

Qualitative semi-structured interviews

Feasibility

Acceptability

Limitations of the study

Pre-publication history

Acknowledgements