Introduction
Access to education and health are human rights (World Health Organization [WHO], 2022). Health Promoting Schools (HPS), also referred to as Comprehensive School Health (CSH), is a whole-school approach that shifts the focus from individual behaviours to a school-wide effort to enhance health and learning by establishing a school environment in a planned, integrated, and holistic way (Joint Consortium for School Health, 2023; WHO & UNESCO, 2021). The World Health Organization (WHO) suggests that healthy children and youth can achieve better educational outcomes which, in turn, leads to improved health later in life (WHO & UNESCO, 2021). While HPS efforts do not explicitly target individual behaviours, participation in HPS activities is associated with positive health behaviours in students, including an increase in physical activity (Fung et al., 2012; Langford et al., 2015), improvements in healthy eating behaviours (Fung et al., 2012; Langford et al., 2015), enhancement of personal development skills (Stewart-Brown, 2006), better mental health (Dassanayake et al.2017; Stewart-Brown, 2006), improvements in academic achievement (Centeio et al., 2021; Lee et al., 2020), and decreases in bullying (Langford et al., 2015). A HPS model encompasses four distinct, but inter-related components: 1) School Environments (Social and Physical), 2) Teaching and Learning, 3) Health Promoting Policies, and 4) Services and Programs (Government of Nova Scotia, 2015; 2023a) (Table 1). Taking a HPS approach not only requires action among the model components but requires fundamental processes to successfully implement the approach including: 1) Leadership and Partnerships 2) School Community Engagement (including children and youth); and 3) Planning and Evaluation (Table 1).
Table 1. Health Promoting Schools components and processes adapted from Nova Scotia’s Provincial Guiding Document (Government of Nova Scotia, 2015;2023a)
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Since children and youth spend much of their waking hours within school communities, schools are an essential setting for health promotion (WHO & UNESCO, 2021). Despite the potential impact of the school setting on student population health, the responsibility to support child and youth health and learning cannot fall entirely on the education system – a partnership with the health system, among other departments, ensures best practices and expertise in health promotion are integrated within education settings (WHO & UNESCO, 2021).
In Canada, provinces and territories are responsible for the development, delivery, and sustainability of HPS, generally through partnerships between the Ministries or Departments of Education and Health. While there is no direct federal government oversight of, or involvement in, HPS, the federal government supports a Federal-Provincial-Territorial table known as the Pan-Canadian Joint Consortium for School Health (JCSH), that brings together health and educational sectors across jurisdictional boundaries to collaborate and coordinate HPS activities. A lack of federal direction can result in variability in HPS implementation across jurisdictions while also allowing for experimentation and diffusion of new practices and learning between provinces and territories. National organizations like the Canadian Healthy Schools Alliance (2021), offer support to provinces and territories so that HPS can be implemented in a more consistent manner to achieve desired health and education outcomes.
Despite these efforts from national organizations, there is still significant variability in HPS delivery among Canada’s provinces and territories; therefore there is value to work towards a collective national vision for HPS to aid in advancing the model’s development and implementation. That said, there is a need to provide context and detail on each provincial or territorial HPS model and to share learnings across jurisdictions. In this paper, we outline the past, present, and future state of HPS in the province of Nova Scotia (NS), as an example of a novel, multi-sectoral HPS partnership in action. NS offers an excellent example of how HPS implementation is a collaboration between provincial, regional, and school community level partners that has evolved over time, resulting in a top-down model approach that is variable across regions and school settings (McIsaac, Mumtaz, et al., 2015). While researchers have previously briefly documented the progress of HPS activities in NS (McIsaac, Kirk, et al., 2015), the full history and evolution of the model to date has yet to be described and shared widely. This commentary also shares a timeline (Figure 1) to illustrate the research, policy and practice endeavours that have propelled HPS in NS forward. This commentary is written from the perspectives of HPS researchers and practitioners in Nova Scotia who hope to share our HPS work beyond our province to inform other jurisdictions of our learnings, accomplishments, and opportunities for improvement.
Past: How it started
HPS has a rich history of research and practice in NS, starting in 1997 with the Annapolis Valley HPS Project, a grass-roots initiative that worked towards embedding more nutritious food into the school menu leading to an established school food program and school board food policy (Edwards et al., 2004). Shortly after, researchers at Dalhousie University conducted the Children’s Lifestyle And School-performance Study (CLASS) in 2003, a province-wide research project studying relationships between health and academic performance. CLASS reported that Grade 5 students who were part of the Annapolis Valley HPS project had lower rates of overweight and obesity, better eating behaviours, were more physically active, and less sedentary than students attending other schools in the province (Veugelers & Fitzgerald, 2005). During this time, NS was the only province in Canada to have a Department of Health Promotion and Protection (established in 2002, later merging into the Department of Health and Wellness in 2012) separate from the Department of Health. This department was responsible specifically for matters related to health promotion and prevention, including physical activity, healthy eating, sexual health, injury prevention, addiction, and tobacco control, leading to a dedicated focus on initiatives including HPS. Of note, HPS was formally initiated in NS in 2005, as a partnership between the Department of Education and Early Childhood Development (DEECD), and the Department of Health and Wellness (DHW) to provide funding and provincial capacity building to NS Health (formerly District Health Authorities) public school boards (now Regional Centres for Education [RCE], the French language school board, Conseil scolaire acadien provincial [CSAP]) and Mi’kmaw Kina’matnewey, that supports Mi’kmaq schools across Mi'kma'ki (Nova Scotia). In alignment with the initiation of HPS, many related frameworks, strategies and action plans were introduced in NS that to enhance student health and well-being during these formative years, including Active Kids, Healthy Kids, a physical activity strategy (Government of Nova Scotia, 2002), Learning for Life II: Brighter Futures Together, a plan for public education (Government of Nova Scotia, 2005), the Food and Nutrition Policy for public schools (Nova Scotia Department of Education and Nova Scotia Department of Health Promotion and Protection, 2006), Healthy Eating Nova Scotia’s Strategy (Nova Scotia Alliance for Healthy Eating and Physical Activity & Nova Scotia Office of Health Promotion, 2006), and Nova Scotia’s Chronic Disease Prevention Strategy (Unit for Population Health and Chronic Disease Prevention, 2003). These represent some of the strategies and initiatives introduced with the objective of strengthening HPS in Nova Scotia, as referred to in Figure 1.
In 2011, a follow-up study to CLASS (CLASS II), investigated whether there had been changes in children’s health behaviours since 2003. Despite the introduction of HPS and related policies (e.g., Food and Nutrition Policy for Public Schools) starting in 2005, students’ diet quality and screen time were similar, physical activity was lower, and, interestingly, students were not fully benefiting from more intense implementation of school health promotion policies compared to 2003 (McIsaac, Chu, et al., 2015). Similar results were found in the 2013-2016 Tri-County Regional School Board (TCRSB) HPS evaluation that reported only small differences in student health behaviours between schools with and without voluntary HPS implementation (McIsaac, Penney, et al., 2017). Other research reiterated the need to focus on health promotion interventions for children and youth. For instance, the province-wide Keeping Pace surveillance study monitored trends in health behaviours of students in grades 3,7, and 11 in 2009-2010 and reported that while 80% of students in Grade 3 met the physical activity standards, less than 30% met the standard in Grade 7, and less than 5% of students met the standard in Grade 11 (Government of Nova Scotia, 2012). In the same study, it was also identified that most students did not meet the minimum recommended servings from Canada’s Food Guide.
These mixed effects of HPS outcomes across schools sparked further research to elucidate the factors that enabled or hindered HPS implementation (McIsaac, Storey, et al., 2015; McIsaac, Read, et al., 2017). This provincial work identified that system-level factors, including organizational capacity, school and student engagement, and distribution of leadership are important influencing factors in HPS implementation. The evolving focus on HPS implementation aligns with wider Canadian research, suggesting that understanding the how and why of HPS effectiveness rather than solely understanding the outcomes of student behaviour is essential to examine the factors that enable health promoting versus health hindering environments (Neely et al., 2020; Penney et al. 2017; Storey et al. 2016). Concerns for developing health promoting environments for child and youth health were further echoed through provincial government calls to action outlined in the Nova Scotia government plan, Thrive! A plan for a healthier Nova Scotia (Government of Nova Scotia, 2012) that aimed to address childhood obesity and preventable chronic diseases with a focus on healthy eating and physical activity through a health promotion lens. This whole-of-government plan emphasized building on past progress, including the provincial school food and nutrition policy, while specifically signalling a need to “reshape the places where we live, learn, work, commute and play” to enhance the health of Nova Scotians (Government of Nova Scotia, 2012).
The focus of the Thrive! strategy on children and youth led to the endorsement of a HPS provincial guiding document, Education and Health: Working together to enhance healthy school communities in 2015 (Government of Nova Scotia, 2015). The document outlined the vision for HPS in Nova Scotia that “Children and youth thrive in healthy school communities” and the mission to “Create and support healthy school communities where student learning, health, well-being and overall achievement are improved” (Government of Nova Scotia, 2015). At the time, HPS in Nova Scotia adopted the four interrelated pillars of the Joint Consortium for School Health (Table 1) to guide this work across six substantive areas of focus: mental and emotional health, physical activity, healthy eating, substance use and gambling, injury and communicable disease prevention, and sexual health (Government of Nova Scotia, 2015). The document also outlined the following guiding principles to support HPS implementation in Nova Scotia: support schools to be healthier places, social justice, involvement and engagement, partnership and collaboration, evidence, and evaluation (Government of Nova Scotia, 2015). Yet, this provincial leadership around HPS was overshadowed by a shift in the political structure provincially that resulted in the amalgamation of nine NS district health authorities into one province-wide Nova Scotia Health Authority (NSHA) (Government of Nova Scotia, n.d.). While the goal of this merger was to improve efficiency and contain health costs it brought with it the opportunity to build greater alignment and coherency across the provincial health system. However, there were opportunity costs when it came to program development (Fierlbeck, 2019). The merger led to a reassignment of the operational aspects of HPS from the DHW to Public Health within NSHA including provincial planning, funding administration and regional accountability .
Present: How it’s going
Despite the challenges with health and education restructuring, HPS has continued to be a joint partnership between DHW, DEECD and the NS Health Public Health team. However, funding for HPS comes through the public health system, which has been consistently underfunded provincially (Caldwell et al., 2021). Research suggests the case for increased funding for public health is strong. Recent international research identified a return of investment of $14 for every $1 invested in public health interventions (Masters et al., 2017). HPS approaches alone, when fully implemented, have been estimated to have a return on investment of over $8 CDN in future direct healthcare costs for the treatment and management of chronic diseases for each dollar invested (Ekwaru et al., 2019).
Building on the past research conducted in Nova Scotia, and in recognition of the need for a systems approach to enhance HPS implementation factors, in 2016 a school-community-university partnership was formed in NS. Evolving into the UpLift Partnership, this collective effort is a partnership designed to secure funding, leverage existing HPS investments and enhance the HPS model through increased child and youth engagement, robust evaluation, and capacity building. Critically, the UpLift Partnership is not an alternative to current HPS work in NS but rather a catalyst to increase the reach and impact of HPS across the province. In 2019, funding was secured from the Public Health Agency of Canada (PHAC) multi-sectoral partnerships to Promote Healthy Living and Prevent Chronic Disease – a unique matching-fund pledge with private sector donors (total funding envelope of $7.8 million) to catalyse HPS over six years.
The UpLift Partnership engages education and health sectors, including NS Health, DHW, and DEECD, along with the Department of Communities, Culture, Tourism, and Heritage (CCTH), the Public School Administrators Association of Nova Scotia (PSAANS), and Dalhousie University, to enhance HPS in six interrelated domains: 1) Partnerships and Leadership, 2) Planning and Evaluation, 3) Communications and Knowledge Exchange, 4) Capacity Building, 5) Child and Youth Engagement and 6) School and Community Engagement and Action. Aligning with the essential conditions for HPS outlined in Storey et al. (2016), a core tenet of the UpLift Partnership is to focus on advancing HPS child and youth engagement initiatives. Most noteworthy is the development and hiring of provincial and regional Youth Engagement Coordinators (YECs) to work directly with students on school health initiatives. YECs aim to enhance child and youth engagement efforts in HPS by working towards the meaningful involvement of students in school health promotion projects, initiatives, and strategies. For example, UpLift provides Student Action Grants where YECs work with participating student groups across the province to support students in leading the development, organization and implementation of projects related to school health and well-being. The UpLift Partnership was launched in a phased approach and now spans elementary, middle, and high schools in five of the seven school regions (Regional Centres of Education [RCE]) – Tri-County (TCRCE), Chignecto Central (CCRCE), South Shore (SSRCE), Annapolis Valley (AVRCE), Strait, as well as in the French-first language school board (CSAP). As of 2023, the UpLift Partnership is in its fourth year of implementation and through ongoing evaluation and research (Graham-DeMello et al. 2021; UpLift Partnership, 2022; Kontak et al. 2022) has assessed the strength of partnerships, identified capacity-building opportunities for teachers and administrators, refined the role of the YECs, and is developing a sustainability plan for authentic child and youth engagement and enhanced HPS implementation beyond the funding period.
In the middle of the UpLift Partnership lifespan, the Province of Nova Scotia (external to UpLift) developed the Healthy Schools Fund to provide each school in the province with $5000 plus $1 per student annually for programs and activities that support physical and mental health, and cultural awareness (Government of Nova Scotia, 2021a; 2023b). Further, the NSH is currently updating their 2015 HPS guiding document with adapted terminology and a refined focus to highlight the importance of HPS processes that act on the components of the model (outlined in Table 1) (Government of Nova Scotia, 2015;2023a). These current and on-going congruent efforts related to HPS are particularly timely given two recent reports about the health and well-being of children in Nova Scotia. In Fall 2022, the Auditor General released a report on healthy eating in schools that found 40% of schools were not compliant with the Nova Scotia Food and Nutrition Policy and that there is great variation between schools and regions (Office of the Auditor General, 2022). This implementation gap has also been identified through previous research endeavours (McIsaac et al., 2018, 2019). Also in 2022, the One Chance to be a Child report highlighted the gaps in government policies and health promoting services available for Nova Scotian children and youth (Department of Pediatrics and Healthy Populations Institute, Dalhousie University, 2022).
Future: Where it’s going
The past and present trajectory of HPS in Nova Scotia highlights the power of leveraging partnerships, aligning goals, and embedding initiatives into existing processes and structures to advance HPS, as well as outlining the implementation gaps needing further action. Of note, the UpLift Partnership has specifically worked towards enhancing implementation factors to enable HPS, including strengthening collaborative processes across sectors through its governing and guiding structures, developing a robust and standardized evaluation framework supporting the HPS model to align visions (UpLift Partnership, 2022) and enhancing child and youth engagement across the HPS approach.
As HPS implementation and investment continues in Nova Scotia beyond the lifespan of UpLift, sustainability of implementation strategies needs to be at the forefront, including continued use of the UpLift evaluation framework to monitor process and support accountability around the money invested in the model, as well as embed child and youth engagement more firmly within HPS approaches. Opportunities to do this include embedding the YEC roles within health or education beyond the life of the current UpLift funding to build capacity for child and youth engagement that enhances health and learning outcomes. Current provincial public health and education priorities are well-aligned to maintain and expand the HPS progress that the UpLift Partnership has catalyzed (Government of Nova Scotia 2021b; 2021c).
Figure 1. Timeline of Health Promoting Schools in Nova Scotia
Conclusion
HPS is a complex, whole-school approach adopted across Canada that aims to shape the conditions necessary to support the health and well-being of the school community. With the dynamic nature of HPS comes variability in its development, implementation and effectiveness across the country. In moving towards a collective national vision of HPS it is necessary to outline the contextual details of each provincial or territorial HPS model to share learnings and opportunities for improvement. This commentary outlines the past, present, and future state of HPS in the province of Nova Scotia, Canada to showcase how HPS has evolved since its inception through a dedicated commitment across research, policy, and practice.
Overall, HPS in NS has evolved and progressed, with increasing buy-in and support over the past 17 years, despite challenges presented by political and institutional restructuring. This enduring partnership between education and health sectors demonstrates a commitment to continuous evaluation and adaptation to advance the goal that every school environment in NS prioritizes health and well-being as an essential component of student achievement. With adequate structures, educational resources, government investment, and school-community leadership and partnerships, HPS in Nova Scotia can deliver “a triple dividend for students today, the adults of tomorrow, and the generation of children to come” (WHO & UNESCO, 2021).
We hope this overview of HPS in NS will encourage other provinces to document their unique experiences with HPS implementation. We invite readers to share their stories of HPS to strengthen our collective understanding of HPS in Canada.
Authors
Julia C.H. Kontak, PhD candidate, Faculty of Health, Dalhousie University, and Healthy Populations Institute, Dalhousie University, ORCID: 0000-0002-9104-0678
Hilary A.T. Caldwell, PhD, Healthy Populations Institute, Dalhousie University, ORCID: 0000-0003-2951-4542
Elyse C. Quann, BSc, Healthy Populations Institute, Dalhousie University
Camille L. Hancock Friesen, MD, Healthy Populations Institute, Dalhousie University, and Division of Pediatric Cardiothoracic Surgery, Children’s Health and Medical Centre, University of Nebraska Medical Center
Steve Machat, PhD candidate, Healthy Populations Institute, Dalhousie University
Kari Barkhouse, MPH, Science and System Performance Unit, Public Health, Nova Scotia Health, 215 Dominion Street, Bridgewater, Nova Scotia, B4V2K7
Sara F.L. Kirk, PhD, School of Health and Human Performance, Faculty of Health Dalhousie University, and Healthy Populations Institute, Dalhousie University, ORCID: 0000-0003-2146-4448
Acknowledgements
The research was supported by an unrestricted grant related to the topic under study from the Public Health Agency of Canada, as well as a Canadian Institute for Health Research (CIHR): Frederick Banting & Charles Best Canada Graduate Scholarship - Doctoral Award (175916) (to JCK) and a CIHR Health System Impact Fellowship- Post-Doc Award (to HATC).
Conflict of interest
SFLK and CLHF designed and co-lead the operationalization of the UpLift Partnership to catalyze Health Promoting Schools implementation and evaluation in the province of Nova Scotia. SFLK, CLHF, and KB are members of the UpLift Advisory Committee and SM was a past member.
Author contributions
JCK, HATC and SFLK conceptualized the study design. JCK, HATC and ECQ drafted the initial draft of the manuscript. JCK, HATC, ECQ, SM, KB, CLHF, and SFLK, edited and reviewed the final manuscript.