Search methods

The search aimed to identify the textual and narrative evidence from the literature on health promoters’ experiences in implementing HPS. Four electronic databases, CINAHL, Ovid, Medline and Web of Knowledge, were searched, as well as The Journal of School Nursing and the Journal of School Health. The databases were searched for the period from 2002 to December 2012, so that the selected articles would be relevant to the current societal and educational climate [19]. The date of the last search was 31 December 2013. A combination of keywords and thesaurus terms was used in the databases: health promoters (or health promotion actors, principals, teachers, school nurses, stakeholders), AND school (or school-based), AND health promotion (or promoting school, comprehensive school health, and coordinated school health), AND qualitative research (or focus groups, grounded theory, semi-structured interviews and framework). The results obtained were then combined with experience, strategy, programme and/or implementation. Reference lists of related articles were reviewed, and experts in the areas were approached to suggest relevant studies. In order to achieve a broad scope of literature, there were no restrictions on language, publication type or study design. Non-English articles were only excluded for eligibility at the full-text assessment stage. Studies were included if (a) the research included health promoters (principals, teachers, school nurses and/or other staff involved in school health promotion), and (b) the study aimed to explore the views of the process of implementing health-promoting schools.

The review employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement [20]. The PRISMA flow diagram (Figure S1 and Checklist S1) illustrates the process followed in this review.

Quality appraisal

The Critical Appraisal Skills Programme (CASP) Qualitative Checklist was used to assess the quality of the six included studies [21]. It contains 10 questions (items) which guide researchers in reviewing qualitative studies. Each item was checked “Yes”, “Can’t tell” or “No”. Under each item, there were hints (guiding questions) for consideration. For items that were checked “Can’t tell” or “No” in the appraisal, comments were given independently and discussed between the first and last authors (TTMH & RLTL) in case of disagreement (Table 1). All the six included articles were checked “Yes” for items 1, 2, 3, 7, 8, and 9. The comments are discussed in the following paragraphs.

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Table 1. Summary of characteristics of the six included articles (part 1/3).

https://doi.org/10.1371/journal.pone.0108284.t001

Inchley et al. [27] did not fully explain how and why they selected the “key stakeholders” for in-depth interviews, or the criteria for student and teacher selection in the focus group interviews (item 4). Pryjmachuk et al. [31] conducted focus group interviews in which all of the participants were female. However, they did not explain why or the potential bias in their results due to the absence of young males (item 4). Keshavarz et al. [28] did not report how they interviewed the staff (item 5). Inchley et al. [27], Keshavarz et al. [28], Morberg et al. [29], and Gugglberger [32] inadequately considered the relationship between researcher and participants in the data collection, discussion and limitations sections of their articles (item 6).

However, all six studies were considered as having passed the quality appraisal after being scrutinized and evaluated by the four authors, as they were important in contributing qualitative evidence relating to health promoters’ experiences in implementing HPS (item 10).

Data abstraction

All articles were read and the data extracted by two reviewers (TTMH & RLTL) who made decisions regarding inclusion or exclusion. Where possible, consensus was obtained by meeting to compare decisions. In the event of disagreement, a third reviewer (VCLC or AD) read the articles and contributed to decisions and consensus.

Synthesis

According to [16], one of the purposes of narrative synthesis is to organize findings from included studies in order to identify and list the enablers and the strategies supporting implementation, as well as exploring the relationship between the reported enablers and the supportive strategies. The descriptions may point to a linear process, yet it is a back and forth process in which the synthesis begins as early as in the line-by-line coding [22]. The synthesis was done by data extraction from all of the text labelled as “results” or “findings” in the included studies [22]. Coding was done with the focus on the aim of the present study, at the same time being open-minded to allow for the possibility of different or better fit of codes emerging [22], [23]. Each reviewer did the coding and synthesis independently, and through discussion more abstract or analytical themes began to emerge.

Enabler 1: Following a framework/guideline to implement HPS

Keshavarz et al. [28] and Morberg et al. [29] mentioned that a clear, well-defined and systematic framework of HPS is needed in order to carry out specific programmes successfully. Even policies that were “evidence-informed” might not yield similar outcomes due to the diversity in and between schools, which should be addressed by health promoters and external stakeholders so as to formulate realistic health goals for different schools [28]. Keshavarz et al. [28] also reported that there were not many guidelines that might direct schools to become HPS, nor would the schools follow externally imposed ones. Echoing Keshavarz et al.’s notion of setting up realistic health goals for different schools, Gugglberger suggested that school health promotion should be “precisely structured with certain phases, aims and milestones”, and that “systematic proceedings are necessary for a mutually successful project” ([32], p. 452). Thus, the schools following the HPS framework should consider tailoring their efforts to the individual local context [28]. As reported in the included studies, some health promoters viewed HPS as “add-ons” [27] and “taking extra time” [28], often competing with other programmes or basic routines [30]. As a result, the health promoters, particularly teachers and school nurses as reported, had to prioritise their work, although health promotion was usually given lower priority than “educational achievement” [27], [28], [30].

The staff might lose their enthusiasm for carrying on the school health promotion work, regardless of the apparent immediate results, because a sense of ownership by the individual school was insufficient [27]. In order to develop this sense of ownership, the HPS framework should enable “each member to play a much fuller role in strategic planning and professional decision-making” [27]. The health promoters should also be empowered with the autonomy to set health promotion as the priority [29], with the framework/guideline being flexible in its interpretation, assessment of school needs, developing aims and objectives of school health promotion, allocation of budgets, implementation and evaluation of outcomes [27], [28].

Enabler 2: Obtaining committed support and contributions from the school staff, school board management, government authorities, health agencies and other stakeholders

A number of studies in this review identified the critical role of the school board management in supporting the implementation of HPS in terms of finance, coordination, policy and commitment [27]–[30], [32]. “[The support] is the duty of the school administration, it’s a very important function… otherwise the school [will] get lost” ([32], p. 452). “It’s scary how crucial [senior management] are because it can be frustrating… because there is no support” ([27], p. 68). The principal’s individual motivation played a key role in establishing relationships and fostering interactions between schools and the health sector, and also between the health-promoting schools [28], [32], which in turn facilitated the exchanges of health-related knowledge, experiences, and resources [28]. As also mentioned in Enabler 1, the sense of ownership and empowerment was related to financial support, especially if the health promoters “could spend that money how they felt it should spent” ([27], p.68). Another request for financial support from the school board management is to pay for the over-time work and extra contributions of the health promoters, particularly the teachers. One of the researchers commented that “[the lack of] financial incentives for teachers was therefore identified as the biggest hindering factor for HP [health promotion] intervention by the actors” [32].

Besides the support from the school board management, the attitudes and the commitment of the school staff played a vital part in the success. A positive attitude such as not seeing the HPS as an “add-on” [27], and the willingness to commit time [28] determined the contribution of the health promoters. For example, huge workloads and time constraints were commonly reported in most of the selected studies [27], [28], [30], [32]. “Many of the staff have said, ‘I haven’t got any time to give [to health], apart from the normal sport time’ ” ([28], p. 1471). Some health promoters were motivated by appreciation for their efforts from external parties (such as the media and politicians), which could sometimes compensate for the lack of incentives [32]. Certificates awarded to the schools which “make the school achievements visible” also served this purpose [32].

While the health promoters perceived such recognition as crucial to their motivation in school health promotion, attitudes towards health or the culture of society also affect health promoters’ motivation: “[health] gets pushed to the side… It’s better that the child be fat than that the child get low marks. Why? Because society thinks [academic achievement] is more important, a lot of people anyway” [28, p. 1471, emphasis in original]. This culture might also be transmitted through the media: “Because then the media comes at you and says why aren’t you teaching kids to read properly and we [teachers] get the blame” ([28], p. 1471).

Food suppliers’ commitment contributes to the success of HPS. Keshavarz et al. [28] reported that “the banning of advertising and selling ‘unhealthy food’ in canteens led to the food suppliers’ practice of providing more healthy options” ([28], p. 1471–1472). Therefore the school board management has to make policies to ensure that the food supplied and purchased is healthy for the children [28]. Gugglberger [32] found that the health promoters perceived that they obtained more support when consultation was given to their schools individually. Other support that the stakeholders could offer included health information and manuals, workshops and training in school health promotion, and symposia that facilitated exchange of knowledge and experiences [32].

Enabler 3: Adopting a multidisciplinary, collaborative approach to implementing HPS

The health promoters believed that a multidisciplinary, collaborative approach brings “long-term and sustainable effects” in school health promotion [27], [32]. It fosters the exchange of experiences and ideas in implementation of HPS [27], [29], [30], [32]. Inchley et al. [27] reported that health promoters like to work in multidisciplinary teams within which experiences and resources can be shared. Some health promoters commented that different people in the team should have a “clear and distinct role” [27] or “a clear division of responsibilities” [30], so that they could focus on their professional areas, such as providing medical care by school nurses [29]–[31], managing catering services by catering managers [27], quality development for health promotion activities by activity managers [29], and administration and management by head school nurses, head teachers and principals [28], [29]. Inchley et al. [27] also found that establishing a common understanding of underlying principles and values and negotiating mutually agreed goals and expectations are crucial in a multidisciplinary team.

Collaboration was not just restricted to adopting a whole-school approach within individual schools [27], [32]. Gugglberger [32] reported that health promoters sought more cooperation and collaboration with other schools in different provinces and countries through various means such as regular meetings, information exchange, mutual sharing and learning, and discussion of problems and solutions. Inchley et al. [27] identified “three spheres” of collaboration: partnership working with external professionals, pupil participation and parental involvement. For example, catering staff were invited to share information about their school meal service at a “parents’ evening”, and a student council gathered student opinions and suggestions that informed changes and improvements in school facilities and policies [27].

Enabler 4: Establishing professional networks and relationships

Professional networking and relationship building is an essential component in gaining support and consultation for the implementation of HPS [27], [29]–[32]. Health promoters, particularly school nurses, indicated that they liked working with school doctors, paediatric specialists, skin specialists and ear specialists [30]. Some health promoters found it supportive to have a “coordinated school health nurse” [30] or external governmental agencies to help them in school health promotion and coordination, such as the “child and adolescent mental health service provision [CAMHS]” [31] and the “school health service [SHS]” [30]. In case of emergencies, the school nurses had to make appropriate referrals or seek professional advice from private practising specialists [30]. Sometimes the schools invited the specialists to gives presentations and lead discussions on students’ problems [30].

Maintaining good relationships with colleagues within schools as well as with politicians and organizational leaders outside schools has been described as an essential element in the success of HPS [29], [31]. A close working relationship also facilitated communication, information exchange, and sustaining continuous collaborative efforts between the schools and the community, especially when the health promoters responsible for the coordination worked only part-time or during term-time [31]. Further, a “trusting and good relationship” fosters peer supports in the workplace [31]. Inchley et al. noted that a coordinator in school health promotion is “the glue in keeping everything together and making contacts” ([27], p. 69).

Enabler 5: Continuing training and education in school health promotion

According to the findings of studies included in this review, health promoters seek further training and education to overcome obstacles in implementing HPS projects [29]–[31]. The school nurses described their work as ranging from being lonely at work to having a well-functioning network and support system [30], such as the established professional networks and relationships mentioned in Enabler 4. Health promoters, particularly school nurses, reported a lack of confidence in school health promotion even though they had had training and possessed qualifications in health care [29]. For example, some health promoters asked themselves “how do I integrate this into everyday school life, how should I do this, how does it work?” ([32], p. 451), and a few school nurses expressed feelings of inadequacy in terms of their experience acting as a school health nurse” [30]. Some school nurses worried more about doing counselling or giving out inappropriate health advice to students than about the inaccuracy of their health knowledge [31]. This lack of confidence placed extra stress on health promoters with regard to delivering health promotions in schools [31].

Health promoters, especially school nurses, viewed continuing medical education and training in school health promotion as an important way to deliver quality health promotion in schools [29], [30]. Some school nurses tried to gain more confidence by reading journals and research articles when they perceived a lack of theories and methods in their general health promotion work. However, health promoters might be discouraged from taking such expensive courses, thus financial support is important in this regard ([30], p.160).

From policy and guideline establishment to the role delineation of health promoters

Schools possessed different health promotion policies and guidelines, but the interpretations varied among health promoters. Comments on these policies and guidelines ranged from stating that they gave the health promoters more autonomy in implementing HPS to complaining of vague and unclear interpretations that did not help very much in health promotion work and in turn affected the motivation of health promoters. The WHO HPS Framework [36] notes that the users of the guideline should implement it in a way that best fits the individual context and culture; however, as reported in this review, many societies tend to focus on academic achievement [28], which may result in enthusiastic health promoters compromising their motivation and intention in developing the school into a HPS. As evidence in the included studies, adaptation to HPS policies would require a re-prioritization of tasks [28], [30]. The role of fulfilling class teaching by teachers often has to compete with sparing time for classroom health education; this supports the notion of incorporating health education and promotion into the school curriculum [1], [2], [15], [33]. However, this strategy may not necessarily yield positive results, as some health promoters still think that health promotion is not their main role in schools [28], [33]. Interestingly, although the collaborative approach of HPS has been largely emphasized in the included studies, it is seldom mentioned or elaborated how different health promoters see each others’ roles or how they communicate, discuss or clarify among each other. None of the included articles address this possible gap in the perspective of school policy and management, nor could the existing literature provide correlative or comparative studies on this aspect due to the diversity of health promoters’ roles, even among school nurses themselves [19]. For example, Morberg et al. reported that school nurses’ autonomy and legitimacy for work, including school health promotion, actually depended on “trust and a good relationship between the head school nurse and the head teachers” ([29], p. 816), rather than being clearly delineated by existing policies or guidelines. Wainwright, Thomas & Jones [19] also argued that the transition from a teacher-led health promotion conscience to a nurse-led health promotion initiative still raises a lot of conflicts regarding role and professional boundaries. For example, it is not unusual for the existence of school nurses to be based not only on their functional role, but also on the fact that others think that they “bear full responsibility”, and that still others even think that school nurses need not be present permanently in schools [33]. The purpose of the discussion at this point is not to judge whether the existence of certain healthcare professionals, such as school nurses and other specialists, is necessary or suitable in schools, but as a matter of fact that reflects the reality that mutual agreement on the role of different health promoters in implementing HPS has not yet been reached. The authors here argue that the existence of clear policies and guidelines for different health promoters which delineate clearly their roles and responsibilities would improve school nurses’ role and autonomy in school health promotion.

Coordination is the key to obtaining support and resources

In terms of committed support sought within schools, the top-down managerial approach and the bottom-up commitment approach have been identified from the included articles (Table 4–9) and discussed in the systematic reviews focusing on experimental studies only [1], [2], [9], [15]. Principals and other senior staff who held the manager or supervisor role focused more on strategies for effective HPS implementation, which would draw resources from the community and other stakeholders [17]–[29], [32], such as through marketing and obtaining awards and political recognition?. In contrast to junior teachers or school nurses, they were more focused on personal professional development, such as obtaining professional training and extending their career path [30], [31]. The discussion here is not to compare different health promoters’ position, their knowledge and professionalism or intelligence in any sense, but rather aims to emphasise the diversity and complexity of schools as organisations, in the same way that [28] proposed viewing HPS in light of the complex adaptive system. The authors here argue that in order for a school to obtain all the support required, as identified from the included studies, coordination is the key. While the WHO proposes the HPS as a whole-school approach, the United States Centers for Disease Control and Prevention [CDC] uses the term “Coordinated School Health” [37], which emphasizes the coordinated efforts within the schools and communities. In addition to the suggestion by the health promoters in the included studies to hire full-time school nurses, the CDC stresses hiring a full-time or part-time school health coordinator, who helps to “maintain active school health councils and facilitate health programming in the district and school and between the school and community”, and to facilitate policy and cultural changes in the society [35]. The lack of such coordinated efforts was evidenced in the included studies, in which health promoters frequently lamented the lack of between-school communication, cross-provincial and international exchanges, social recognition and a favourable societal culture, but rarely assimilated the coordination role as their own task. This may be due partially to unsophisticated policies and guidelines, which restricted the potential of health promoters to attain the advanced coordination role, and partially to the current lack of financial support from schools and from the government [1], [2], [15], [35]. However, in a more practical sense, the top-down approach would bring a more effective initiating force to introduce and support this coordination role, while the bottom-up commitment, including the participation of parents and students, is still critical for the sustaining the HPS [2], [9]. The coordination role of health promoters, or the school health promotion coordinators, would thus serve as the medium to bridge the top-down and bottom-up efforts within schools, as well as a resource person who obtains support “horizontally” in the community.

Limitations

Several limitations should be taken into account when assessing the contributions of the synthesized findings. Not all of the selected studies discussed and evaluated different types of support, even though financial or funding support is considered to be one of the most important factors for the successful implementation of HPS. One study [32] was conducted in a federalist political structure in which, as described by the author, the availability of resources and the financial and personnel autonomy of schools may be influenced under different conditions. Here the narrative synthesis articles have no political standing and therefore political inferences cannot be drawn.

Inchley et al.’s study [27] was drawn from a process evaluation of a 4-year project undertaken within the European Network of HPS in Scotland, although the schools were funded for a 2-year period only. There is no discussion of how the funding facilitated the implementation of HPS, or the effects on HPS after the funding ceased.

A further limitation concerned the range of the population. Included studies were restricted to the UK, Scotland, Sweden, Austria and Australia, and three of them included only school nurses (Table 1–3). This affects the transferability of the findings [38]. Not all of the studies described the details of the interview techniques used or showed the compositions of their participants, which also affected the ‘thickness of data’. The data is ‘thick’ enough if the author includes detailed descriptions and contextual material from which judgements about the trustworthiness of a qualitative research can be made [36], [37]. Therefore, the qualitative evidence presented in this article may be thin and the interpretations and transferability to other contexts may be limited.

Although the authors consider that the articles included here passed the quality appraisal of the CASP tool, their quality varied. Not all of the studies addressed in-depth reflexivity. In addition, the data analysis was not presented in a rigorous way in every study, limiting the interpretations that can be made. Due to the lack of data from these studies, a theory to describe the implementation strategies or process might not be possible at this stage.