Implementation of “health promoting educational institute” strategies in the state of Himachal Pradesh, India: challenges, opportunities and the way forward

INTRODUCTION

The changing pattern of life has significant impact on health status of each and every individual in the world. Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Therefore, developing and implementing effective health promotion strategies based on local requirements is need of the hour. Health promotion is the process of enabling people to increase control over, and to improve their health.¹ In order to promote health and wellbeing of people at all levels, social, political and community actions are required. To inculcate health promoting behaviour at early stage and to make health a top most priority in life, schools and other educational institutes can play very important role. Based on the guiding principles of Ottawa Charter and recommendations of expert committee, the concept of “health promoting schools” (HPS) was articulated by World Health Organization (WHO) in 1995.² Since then, it has been adopted in many parts of the world with different approaches. A HPS is one that constantly strengthens its capacity as a healthy setting for living, learning and working.² Schools promoting health not only help in building a healthy generation but also play significant role in health promotion of staff, families and community members as well. The health sector has a key leadership role in building of policies and partnerships for health promotion.³ Keeping in view these facts, the department of health and family welfare took the initiative to develop protocols and implementation plan for certification of educational institute as “health promoting educational institute” in collaboration with the education department in the state of Himachal Pradesh in India. In order to ensure the effective implementation of the strategy a joint notification was issued by the health and education department on 6^th November 2020 with detailed protocol and implementation plan.⁴ However the process of the implementation of the plan and certification got delayed due to the COVID pandemic and closure of the schools. As and when the opportunity arrived all possible measures were undertaken for capacity building, awareness generation and to implement the strategy at school level by involving all key stakeholders. As a result, the Government Senior Secondary School Mahunag with strength of 120 students from 6-12^th class in district Mandi was certified as the first health promoting educational institute in the state of Himachal Pradesh on 18^th December 2021 based on the recommendations of the committee constituted for this purpose (Figure 1). The purpose of this article is to discuss the step wise approach for implementation and certification of health promoting educational institute protocols in the state of Himachal Pradesh so that the strategy can be replicated in similar settings.

Health promoting school- global perspective

School health promotion has made a considerable progress in many regions of the world since its beginnings in the early nineties. Development of the school for health in European network (SHE-network) was initiated by WHO (European region) together with the council of Europe and the European commission in 1992.⁵ In Australia and Scandinavian countries health education and health promotion were already mandatory area of school curriculums at that time. To encourage collaboration among existing agencies and to promote the concept of HPS, Australian health promoting school association (AHPSA) was established in 1992.⁶ In Latin America, the health-promoting schools regional initiative was officially launched to strengthen the comprehensive health promotion programmes and activities by Pan American Health Organization, regional office of the WHO (PAHO/WHO) in 1995.⁷ The Latin American and Caribbean networks of HPS were created for the improvement of education and health in the school setting. Regional guidelines were framed in order to support the growth and development of HPS in the western Pacific region of WHO in 1996.⁸ Healthy school award schemes also helped schools to become health promoting in many regions of the world. The Wessex healthy schools award (WHSA) scheme, launched in 1992, was one of them.⁹ In Hong Kong, the centre for health education and health promotion at the Chinese University of Hong Kong (CUHK) first launched the HPS programme in 1998, and further developed the concept of the Hong Kong healthy schools award scheme (HKHSA) in 2001.¹⁰ Other organizations such as the international union of health promotion and education (IUHPE), the Pan-Canadian joint consortia for school health (JCSH) and the ever active schools program (EAS) also offer equivalent guidelines and frameworks for HPS approach.^11-13

Progress of HPS initiative in India

According to article 21-A of the constitution of India, it is fundamental right of every child in the age group of six to fourteen years to get free and compulsory education.¹⁴ As per census 2011, there are 47.3 crore children (0-18) in India, comprising 39 percent of country’s total population.¹⁵ The Indian education system is one of the largest in the world with more than 1.5 million schools, 8.5 million teachers and 250 million children from varied socio economic backgrounds.¹⁶ Therefore, implementation of WHO, HPS model in India will surely have great impact on health of almost every individual of the country. That’s why WHO HPS model was endorsed by the government of India committee in the national meeting of state council for education research and training (SCERT) on school health promotion in 2007.¹⁷ Health related information dissemination amongst youth (HRIDAY), AROGYA world and public health foundation of India (PHFI), collaboratively started an initiative to recognize healthy schools by giving them a healthy school “seal of approval” after qualifying framework criteria.¹⁸ Accreditation system for HPS was developed and implemented in 17 schools of Chandigarh territory in North India (2011-2013).¹⁹ Madhya Pradesh voluntary health association (MPVHA), a local NGO is implementing a project on developing HPS in smart city Indore with the support of John Snow India Private Limited under building healthy cities (BHC) project supported by USAID.²⁰ An attempt of developing a replicable model of HPS using knowledge to action (KTA) framework was made in a school of urban Jodhpur.²¹ Apart from these initiatives, limited studies are available related to HPS concept in India, although some baseline assessments and surveys are available.^22-25

HPS strategy in the state of Himachal Pradesh

Himachal Pradesh, a north Indian hilly state was considered “backward” as the literacy rate of the state was only 31.96 percent when status of full statehood was attained in 1971. As per census 2011 it stands at 83.78 percent which is quite high from national average of 74.04 percent.¹⁵ There are 10723 primary schools, 2029 middle schools, 2801 high/senior secondary schools and 139 government colleges in the state where free education is being provided to girls and specially abled children up to university level.²⁶ Until now, education system was primarily focussed on degree centred education but after realising the rising toll of health related issues among students, the national education policy (2020) incorporated the much needed framework of healthcare in education sector.²⁷ Although many school health initiatives are already being implemented in the state but the adoption of HPS model will surely address the health issues and education together. With this initiative health and well-being of students will be the top most priority so that the State will get healthy, educated and productive adults in future.

Multisectoral approach for development of protocols

Keeping in view the importance of HPS, the state decided to develop and implement the protocols for health promoting educational institutes based on local needs. Rounds of consultative meetings were held with different stakeholders and a strategy was prepared for certification of educational institute as health promoting educational institute based on certain checklist/criteria. The review of literature was done using PubMed and Google scholar to prepare adaptable checklist/criteria for evaluation of the school based on specific needs of a hilly State. “The regional guidelines, Development of health-promoting schools -A framework for action” issued by WHO (regional office for the western Pacific) has been adopted with few state specific modifications.⁸ The six key components of the checklist has been taken from the document published by WHO (western Pacific region) which presents practical advice on the implementation of the key factors based on the experience shared by the National agencies and schools involved in HPS initiative across western Pacific region.²⁸ “Making every school a health-promoting school, global standards and indicators for HPS and system” developed by WHO and the United Nations educational, scientific and cultural organization (UNESCO) in 2021 was also taken into consideration while preparing the checklist.²⁹ The checklist having six broad components are further divided into thirty questions (Table 1).

Implementation of HPS in Himachal Pradesh

A joint notification was issued by health and education department on 06 November 2020 with detailed plan to implement the HPS in the state.⁴ As per notification, grading and certification of the health promoting educational institute will be done based on the scores obtained by the institution. The institute scoring 90 or >90 marks will be certified as “HPS/educational institute”, with 80-90 marks as “achiever” and with 60-80 marks as “aspirant”. As initial step the protocols has to be discussed with all key stakeholders in each school and the gaps has to be identified. The necessary steps have to be taken to bridge the gaps and progress has to be monitored regularly. Following which the concerned institute has to do a self-assessment on given parameters and if scores are >90 in self-assessment, then the head of the institute will apply for the final evaluation to the block medical officer (BMO) concerned. The BMO shall constitute the committee for the inspection and evaluation in which nearest medical officer of PHC/CHC or government hospital, Pradhan of concerned gram panchayat or president of concerned NAC or councillor of concerned MC area and a teacher of the nearest educational institute as peer assessor will be the members. The committee will fix a suitable day for the physical assessment/verification based on the checklist and submit the signed assessment checklist to the BMO concerned. The BMO has to certify the school/institute based on the marks obtained in the checklist. The logistic arrangement for the team has to be made by the health authorities under NCD control program. The certification of the school as HPS is valid for a period of two years and it has to be reviewed after two years.

Certification of first HPS in Himachal Pradesh

After notification of the HPS guidelines and implementation plan, rounds of consultative meetings were held with district level and sub-district level authorities of health and education department. All key stakeholders were sensitized and IEC activities were carried out at all levels. However, the COVID-19 pandemic affected the entire process. But as and when the opportunities arrived the implementation of HPS guidelines was initiated. Following the complete process, the Government Senior Secondary School Mahunag (GSSS Mahunag) in Mandi district of Himachal Pradesh was certified as ‘the first health promoting educational institution” in the state on 18 December 2021. The incharge of the school took the lead and motivated the key stakeholders to identify and to bridge the gaps. After self assessment the school authorities applied for the final evaluation to BMO, Karsog (Mandi). As per the guidelines the BMO constituted the committee for the assessment of the school. The committee visited the school and evaluated it based on the given checklist. All the 6 key components including the healthy school policy, healthy physical environment, healthy social environment, community links, action competencies for healthy living and health care and promotional services were assessed. The overall score of the school was >90 percent in the evaluation done by the committee. Based on the score the school was certified as health promoting educational institution by the BMO. Most of the schools/educational institutes of the state are now following the steps taken by GSSS Mahunag for certification as HPS. The process is expected to be expedited once the COVID pandemic is over

CONCLUSION

As per WHO, every school should be an HPS because no education system is effective unless it promotes the health and well-being of its students, staff and community. The HPS initiative has now existed for more than 25 years, many appreciable works have been done in this field but a full-fledge, replicable and sustainable HPS system does not exist. The state of Himachal has started the implementation of HPS with existing manpower and resources. The standard protocols have been adopted with few states’ specific modifications with multi stakeholder engagements. The department of health and education are playing the key role in implementation of this strategy. The target is to make every educational institute as health promoting educational institute in the state in the minimum possible time. The ultimate goal is to achieve the good health as a long-term strategy by promoting health through school level interventions. Himachal HPS model can be easily replicated in similar setting.

ACKNOWLEDGEMENTS

Authors would like to thank the Chief Medical Officer District Mandi, Dr. Devender Sharma for his guidance and support. They would like to acknowledge Mr. Narender Singh Jamwal (Incharge of the GSSS Mahunag) for his commendable work to make his school as the first Health Promoting School in the state. Also, they would like to thank BMO Karsog Dr. Kanwar Guleria and Pradhan Gram Panchyat Mahunag for the timely assessment of the school.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. World Health Organisation. Ottawa Charter for Health Promotion, first international conference on health promotion, Ottawa. 1986. Available at: https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference. Accessed on 14 February 2022.
2. 2. Jones JT, Furner M. WHO Global School Health Initiative & World Health Organization. Health Education and Promotion Unit. (1998) .Health - promoting schools :a healthy setting for living , learning and working .World Health Organization . Available at :https//:apps.who.int/iris/handle/10665 / 63868 .Accessed on 14February 2022.
3. 3. World Health Organisation. Bangkok Charter for Health Promotion in a globalized world, 6th global conference on health promotion, Bangkok, Thailand. 2005. Available at: https://www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf. Accessed on 14 February 2022.
4. 4. National Health Mission Himachal pradesh. Notification regarding Health Promoting Educational Institute. Available at: http://nrhmhp.gov.in/sites/default/files/files/Health%20Promiting%20Educational%20Instritute%20Notification_06-11-%202020.pdf. Accessed on 07 March 2022.
5. 5. Turunen H, Sormunen M, Jourdan D, von Seelen J, Buijs G. HPS—a complex approach and a major means to health improvement. Health Promotion Int. 2017;32(2):177-84.
6. 6. Rowling L. The adaptability of the HPS concept: a case study from Australia. Health Educ Res. 1996;11(4):519-26.
7. 7. Ippolito-Shepherd J, Cerqueira MT, Ortega DP. Health-Promoting Schools Regional Initiative of the Americas. Promotion & Education. 2005;12:220-9.
8. 8. World Health Organisation. Regional guidelines Development of health-promoting schools -A framework for action; 1996. Available at: https://apps.who.int/iris/bitstream/handle/10665/206847/Health_promoting_sch_ser.5_eng.pdf. Accessed on 07 March 2022.
9. 9. Rogers E, Moon AM, Mullee MA, Speller VM, Roderick PJ. Developing the ‘health-promoting school’ – a national survey of healthy school awards. Public Health. 1998;112(1):37-40.
10. 10. Lee A, Cheng FF, St Leger L. Evaluating health-promoting schools in Hong Kong: development of a framework. Health Promotion International. 2005;20(2):177-86.
11. 11. Young I, Leger L, Blanchard C. Health-promoting schools: working in partnership to address global needs, a collaboration leading to the production of practical tools for practitioners. Global Health Promotion. 2013;20(4):122-7.
12. 12. Hussain A, Christou G, Reid MA, Freeman J. Development of the Core Indicators and Measurements Framework for School Health and Student Achievement in Canada. Pan-Canadian Joint Consortium for School Health (JCSH)(Ed.). Summerside, PE. 2013. Available at: https://educ.queensu.ca/sites/webpublish.queensu.ca.educwww/files/files/Research/SPEG/SPEG%20Core%20Indicators%20and%20Measurements%20for%20School%20Health%20and%20Student%20Achievement%20(1).pdf. Accessed on 07 March 2022.
13. 13. Gleddie D. Assessment for Learning-Healthy Schools Edition. Physical Health Educ J. 2009;75(2):28.
14. 14. Ministry of Human Resource Development: Right of Children to Free and Compulsory Education Act. 2009, New Delhi: Act No. 35, Govt. of India. Available at: http://mhrd.gov.in/rte. Accessed on 07 March 2022.
15. 15. Office of the Registrar General of India, Provisional Population Totals, Paper 1 of 2011 (Office of the Registrar General and Census Commissioner of India, New Delhi, 2011). Available at: www.censusindia.gov.in/2011-prov-results/census2011_paper1_states.html. Accessed on 07 March 2022.
16. 16. UNICEF. Catalysing transformational change in school education. UNICEF, India. 2018. Available at: https://www.unicef.org/india/media/2596/file/Catalysing-transformational-change-in-school-education.pdf. Accessed on 18 February 2022.
17. 17. Ministry of Health and Family Welfare: Report of the National Meeting of the Directors of State Council for Education Research and Training (SCERT) on School Health Promotion. New Delhi 19–21 June 2007. 2007, Government of India, New Delhi.
18. 18. Framework Criteria for Healthy School Seal of Approval, An Initiative by HRIDAY, AROGYA World & PHFI. 2010. Available at: http://arogyaworld.org/wp-content/uploads/2014/07/Framework-Healthy-School-Seal-of-Approval-.doc. Accessed on 19 February 2022.
19. 19. Thakur JS, Sharma D, Jaswal N, Bharti B, Grover A, Thind P, et al. Developing and implementing an accreditation system for HPS in Northern India: a cross-sectional study. BMC Public Health. 2014;14:1314.
20. 20. Bachani D, Pomeroy-Stevens A, Bakhtawar A, Mishra N, Sinha M, Daniel A. Baseline Assessment Report: HPS in Indore. Arlington, VA: Building Healthy Cities (BHC) project. 2020. Available at: https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=23845&lid=3. Accessed on 19 February 2022.
21. 21. Jain Y K, Joshi N K, Bhardwaj P, Singh K, Suthar P, Joshi V. Developing a health-promoting school using Knowledge to Action framework. J Educ Health Promotion. 2021;10:306.
22. 22. Dongre A, Deshmukh P, and Garg B. P1-419 Health promoting school initiative in ashram schools of Wardha district: an evaluation. J Epidemiol Comm Health. 2011;65(1):183.
23. 23. Yuvaraj K, Kumar D, Priyan S, Subitha L, Tanmay G, Vaishnavi S. Assessment of the WHO HPS Framework among schools in selected villages of rural Puducherry, South India – a mixed method study. Int J Adolescent Med Health. 2021;33(2):20180080.
24. 24. Joseph HP, Venkitachalam R, Joseph J, Janakiram C. HPS in Kerala, India. Indian J Comm Med. 2019;44(1):38-41.
25. 25. Periyasamy S, Krishnappa P, Piddennavar R. Adherence to components of HPS in schools of Bengaluru, India. Health Promotion Int. 2020;35(1):174.
26. 26. Economic and Statistics Department, Government of Himachal Pradesh. Economic Survey 2020-21. Available at: https://himachalservices.nic.in/economics/pdf/Economic_Survey_eng2020-21.pdf. Accessed on 23 February 2022.
27. 27. New Education Policy, Government of India, Ministry of Human Resource Development. 2020. Available at: https://www.education.gov.in/sites/upload_files/mhrd/files/NEP_Final_English_0.pdf. Accessed on 24 February 2022.
28. 28. World Health Organization. Regional Office for the Western Pacific. (2017) .HPS :experiences from the Western Pacific Region .WHO Regional Office for the Western Pacific .Available at :https//:apps who.int/iris/handle/10665/254658. Accessed on 04 March 2022.
29. 29. Making every school a health-promoting school: global standards and indicators for health-promoting schools and systems. Geneva: World Health Organization and the United Nations Educational, Scientific and Cultural Organization; 2021. Available at: https://www.who.int/publications/i/item/9789240025059. Accessed on 04 March 2022.