Social Science & Medicine 56 (2003) 1209–1220

A new theory of health promoting schools based on humanfunctioning, school organisation and pedagogic practice

Wolfgang A. Markhama,*, Paul Aveyardb

aSchool of Education, University of Birmingham, Birmingham B15 2TT, UKbDepartment of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT, UK

Abstract

This paper outlines a novel explanatory frame for understanding how schools may intervene in order to promote

pupils’ health. The new theory is synthesised from an Aristotelian interpretation of human functioning and a theory of

cultural transmission. In keeping with recent influential theoretical developments, it is proposed that health has its roots

in human functioning. It follows from this concept that the promotion of pupils’ health is facilitated by the promotion

of pupil functioning and the primary mechanisms through which schools promote pupil functioning and, hence, health,

are through the influences of school organisation, curriculum development and pedagogic practice on pupil

development. According to the new theory, good human functioning is dependent on the realisation of a number of

identified essential human capacities and the meeting of identified fundamental human needs. Two essential capacities,

the capacity for practical reasoning and the capacity for affiliation with other humans, plan and organise the other

essential capacities. The realisation of these two capacities should, it is argued, be the primary focus of health

promoting schools. Additionally, health promoting schools should ensure that fundamental human needs concerning

non-useful pain and information about the body are met. A number of testable hypotheses are generated from the new

theory. Comparisons with existing interpretations of health promoting schools indicate there are similarities in the

actions schools should take to promote health. However, the new theory can, uniquely, be used to predict which pupils

will enjoy the best health at school and in adulthood. Additionally, according to the new theory, schools do not need

designated health education classes or teaching staff with specialist health education roles in order to be health

promoting. It is concluded that the new theory may have a number of advantages over existing theories at both the

policy and intervention levels. r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: School; Health promotion; Human functioning

Introduction

Recent influential theoretical developments in health

promotion are underpinned by the notion that health

has its roots in human functioning (Antonovsky, 1987;

MacDonald, 1998; Marmot & Theorell, 1988; Seed-

house, 1997). In this paper, we outline a new theory of

health promoting schools, which draws on this notion,

and is particularly relevant to adolescents. A funda-

mental concept of this theory is that being autonomous

and in a position to choose to function well and flourish

is necessary to maximise health potential. It follows

from this fundamental concept that the promotion of

health is facilitated by the promotion of pupil function-

ing and the primary mechanisms through which schools

promote pupil functioning and, hence, health, are

through the influences of school organisation, curricu-

lum development and pedagogic practice on pupil

development. When viewed from this perspective,

schools do not need health education classes that focus

on healthy lifestyle choices nor teaching staff with

specialist health education roles in order to be health

promoting. Although many aspects of our new theory

*Corresponding author. Tel.: +44-121-414-7631; fax: +44-

121-414-4865.

E-mail address: w.a.markham@bham.ac.uk

(W.A. Markham).

0277-9536/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 1 2 0 - X

have been loosely discussed and practised under the

banner of health promoting schools, we believe our new

theory provides a rationale for why health promoting

schools should address certain issues and describes how

they should intervene. This rationale is grounded in

existing theoretical perspectives in education, health and

social functioning and, arguably, provides additional

insights into some key elements of the health promoting

school initiative. Our theory resonates with aspects of a

WHO definition of health promoting schools (WHO,

1998) and with the eco-holistic model of health

promoting schools developed by Parsons, Stears, &

Thomas (1996). It is also consistent with commentators’

views regarding the promotion of health within ‘settings’

(Baric, 1992, 1993) and the promotion of health and

community development (Labonte, 1998; Loeb, Mark-

ham, Naidoo, & Wills, 1998).

The new theory is derived from the application of

Nussbaum’s ethical–political account of good human

functioning, outlined in her overview of Aristotelian

social democracy (Nussbaum, 1990), to Bernstein’s

influential theory of cultural transmission (Bernstein,

1975). In this theory, we extend Nussbaum’s account of

human functioning to understand why some individuals

are healthier than others. Nussbaum’s account of

human functioning is used because it has two important

advantages over other interpretations of good human

functioning. First, Nussbaum maintains that her con-

ception of good human functioning is both universal

and flexible. Second, her interpretation is detailed in

nature, although it does not include a detailed analysis

of how schools may be organised in order to promote

human functioning. In this new theory, we apply

Bernstein’s theory of cultural transmission to provide

insights into how schools influence pupils’ psychological

development and social behaviour because it has two

main advantages over other theories that attempt to

account for the same data. First, it relates macro-

institutional forms and constraints to micro-interac-

tional levels and processes. Second, it focuses on the

influences of school organisation, curriculum develop-

ment and pedagogic practice on pupil development,

which are the core activities of schools. Evidence in

support of Bernstein’s theoretical conception of how

individual schools influence pupil’s psychological devel-

opment and social behaviour is provided by Daniels,

Holst, Lunt, and Ulsoe-Johansen (1996). They used

Bernstein’s framework to show that pupils are aware of

the dominant approach to education, internalise the

schools’ expectations and value these in the same way

that the school does. However, Bernstein’s theory of

cultural transmission does not provide a universal

account of good human functioning. We propose,

therefore, a synthesis of the insights of Nussbaum and

Bernstein that builds upon each of these and is

explanatory in nature. From this theoretical position,

we produce a set of predictions on how different aspects

of the educational experience can be used to generate

health amongst pupils while at school and after they

have left and become adults. Health promotion in

schools when viewed from this perspective has the

potential to avoid becoming a bolt on extra. Finally, we

compare our interpretation of health promoting schools

with other commentator’s interpretations.

Nussbaum’s theory of human functioning (after

Nussbaum, 1990)

Through Nussbaum’s conception, we propose that,

irrespective of culture and situation, all humans have

fundamental human needs (Table 1) and inherent

capacities or potentialities (Table 2). The assuaging of

these fundamental needs and the realisation of these

essential human capacities is a pre-condition for

autonomy and for a person to be in a position to

choose to function well and flourish, which we believe is

a pre-requisite for health.

Drawing on Nussbaum (1990), it is acknowledged

that the list of essential capacities may not be exhaustive

and is open to revision. However, once the fundamental

human needs are met, a person who had sufficiently

realised all the capacities in this list (Table 2) would, we

propose, be in a position to be autonomous, and to

choose to function well. Such a person would also fulfil

his/her need to be human (Nussbaum, 1990). Two

capacities from Table 2 are, Nussbaum reasons, over-

arching and organise all others. The first of these focuses

Table 1

The fundamental human needs (after Nussbaum, 1990)

The need for a clean water supply, adequate food, warmth and shelter.

The need to address medical and human concerns that focus on years of life and to provide health care for the sick and/or injured.

The need to provide information about the body.

The need to facilitate the development of skills in order to be able to make appropriate choices concerning health related behaviours.

The need to have pleasurable experiences and opportunities for sexual satisfaction.

The need to be able to avoid unnecessary and non-useful pain.

The need to be able to move freely from place to place.

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–12201210

on practical reasoning i.e. to imagine, think and reason.

The second concerns affiliation i.e. to have concern for

other humans, to live for others, to have familial and

other interactions and attachments. Nussbaum argues

these two capacities are overarching because everything

a person does is planned and organised by her/his ability

to reason and is done with or to other humans.

Nussbaum emphasises that the realisation of the

capacity for practical reasoning is evidenced by the

ability to critically reflect while the realisation of the

capacity for affiliation is evidenced by mutuality (co-

operation for mutual benefit) (Nussbaum, 1990). Draw-

ing on Nussbaum, we suggest that the ability to critically

reflect and having mutually satisfying reciprocal attach-

ments with others are also dependent, albeit to a lesser

degree, on the realisation of the other essential capacities

outlined in Table 2. Thus, once the fundamental human

needs are met, the full realisation of the essential

capacities, as is evidenced by the ability to critically

reflect and mutuality, largely defines and makes

autonomy possible (Fig. 1).

Nussbaum maintains education is the key to function-

ing well because education facilitates the realisation of

most, if not all, the essential capacities especially, the

capacity for practical reasoning. Furthermore, she

highlights the influence of institutions to which a person

is attached, on the realisation of the capacity for

affiliation. The role of schools in promoting the ability

to function well is, consequently, potentially profound in

this theoretical account. She did not, however, consider

how schools should be organised to promote human

functioning. We propose that, the major focus of a

health promoting school should be the facilitation of the

realisation of the essential capacities; primarily the

capacities for practical reasoning and affiliation. Health

promoting schools should also ensure that some

fundamental human needs concerning non-useful pain

and information about the body are met.

Nussbaum’s concepts are, however, theoretical. There

is no common understanding of what the realisation of

the essential capacities, especially the capacities for

practical reasoning and affiliation, and, thus, the ability

to critically reflect and mutuality, might mean in the

context of schooling. Before considering how schools

may be organised in order to facilitate the realisation of

the essential capacities, these key theoretical concepts

need to be operationalised in order that they may be

recognised. This operataionalisation can be achieved

through other social theories, with more detailed and

practical tenets.

Realisation of the capacities for practical reasoning and

affiliation

Through the theories of Bernstein (1975) and Freire

(1989, 1998), we propose that the realisation of the

capacity for practical reasoning enables a person to

critically perceive reality and view problems and

solutions from different perspectives. People in this

position have insights into the potential for multiple

realities and elaborate orientations to meaning, rather

than restricted orientations to meaning which focus on

lived experience. They also have the potential to make

pro-active choices, which are not restricted by external

factors, as well as adaptive choices, which are restricted

Table 2

The essential human capacities (after Nussbaum, 1990)

The capacity to imagine, think and reason and thus to be able to form a conception of the good and engage in critical reflection about

the planning of one’s own life.

The capacity to have concern for other humans, to live for others, to have familial and other interactions and attachments.

The capacity to love, grieve, feel longing for, and be grateful.

The capacity to laugh and play.

The capacity to be able to live one’s own life in one’s own context.

The capacity to have concern for the world of nature.

The capacity to be aware of all the senses.

Assuaging the

fundamental

human needs }} Realisation of the essential

human capacities especially

those related to practical

reasoning and affiliation

} Critical reflection

Mutuality} Autonomy

Fig. 1. The relationships between the fundamental human needs, the essential human capacities and autonomy (after Nussbaum,

1990).

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–1220 1211

by external factors. Pro-active actions have the potential

to transform reality by changing the world in which a

person lives through invention, creation or recreation.

The potential to make pro-active choices is necessary if

the capacity for practical reasoning is to be fully

realised. This interpretation of the realisation of the

capacity for practical reasoning resonates with Piaget’s

views on the development of the capacity for formal

operational thinking (Ginsburg & Opper, 1979), that

was developed by Flavell (1985). People who have

sufficiently developed the capacity for formal opera-

tional thinking are able to reason in the abstract, can be

objective about their own subjective thoughts and are

aware that when seeking solutions to problems they

need to explore alternative possibilities that are not

solely based on lived experience. According to Piaget

(Ginsburg & Opper, 1979), and Flavell (1985), this is the

central cognitive ability commonly gained during

adolescence.

In the same way, through the theories of Bernstein

(1975), we propose that the realisation of the capacity

for affiliation depends on shared values and empathetic

understanding of others’ orientations to meaning.

People who have sufficiently realised the capacity for

affiliation would have mutually satisfying reciprocal

interactions and attachments with others and, conse-

quently, would experience a sense of belonging and feel

socially supported. They would also be in a position to

create a socially valued identity through, for example,

being involved in socially valued decision making. This,

in turn, promotes the development of characteristics

such as self-esteem. This statement recognises that

characteristics such as self-esteem are socially con-

structed, rather than solely derived from the individual.

This interpretation of the realisation of the capacity for

affiliation resonates with Erikson’s view that a key

developmental task during adolescence focuses on the

development of a well defined sense of identity which

involves defining social roles within different contexts

(Erikson, 1968). Cooper, Grotevant, and Condon (1983)

reported that developing a strong sense of identity is

most likely to occur when self assertion and freedom

(separateness) are encouraged within an atmosphere of

responsiveness to the needs of others and sensitivity and

respect for others (mutuality).

This analysis of Nussbaum’s account of human

functioning, therefore, describes what the full realisation

of the capacities for practical reasoning and affiliation

would, in our view, entail. This realisation largely

defines autonomy, makes possible the potential to

function well, and is a pre-requisite for maximising a

person’s health potential. A person in such a position is

able to make choices that are based on a fully developed

ability to critically reflect and fully developed mutual

affiliations. The world is understandable and can be

adapted to suit him/her further. People in this position

have mutually satisfying reciprocal interactions and

attachments and consequently experience a sense of

belonging and feel socially supported. They would

perceive that they had a socially valued identity and

would, consequently, have high self-esteem.

The focus of Nussbaum’s account of human function-

ing is how different forms of government may promote

or retard the realisation of the essential capacities. She

does not discuss in detail the type of educational

experience that would enable a person to realise the

essential capacities. Bernstein’s theory of cultural

transmission enables us to understand and predict how

educational experience may be operationalised to

promote the type of pupil–school interactions that

facilitate the realisation of the capacities for practical

reasoning and affiliation, and hence good human

functioning and health.

Bernstein’s theory of cultural transmission

Central to Bernstein’s theory of how schools are

involved in cultural transmission is the view that schools

relay two inter-related yet separate orders: the instruc-

tional order and the regulatory order. Pupils, according

to Bernstein, may be categorised according to their

responses to these orders. These insights are funda-

mental to our new interpretation of health promoting

schools and are consequently outlined.

The instructional order

Bernstein proposed that the instructional order is

concerned with the ability of pupils to contribute to

future production through work. The aims are to relay

knowledge and skills and to influence pupils’ orienta-

tions to meaning. What is understood as valued

knowledge and skills is shaped by the dominant culture.

Bernstein maintained that the aims of the instructional

order are driven by the knowledge and skill needs

of the state and, in particular, the knowledge and skills

needs of the economy and higher education institutions.

He reasoned that the predominant understanding of

knowledge in UK university settings is that each subject

has defined ways of thinking, knowledge and skills.

States of knowledge in each academic subject are gained

by increasingly deeper enquiry into the subject (Bern-

stein, 1996). He maintains that UK schools are

consequently forced to largely train their pupils to

develop the skills necessary for in depth enquiries and

pupils are generally encouraged to develop an ability to

think and reason predominantly within the context of

particular subjects.

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–12201212

The regulatory order

According to Bernstein, the regulatory order, on the

other hand, is concerned with the conduct, character,

and manner of pupils and focuses on the relaying of

values. The aims are to facilitate the attachment of the

pupils to the schools and the internalisation of the values

and beliefs of the school. Bernstein maintains this helps

to ensure that every pupil functions appropriately within

society while they are at school and after they have left.

The aims of the regulatory order are, he believes,

commonly driven by the set of values and beliefs that are

held outside the school by the ‘controlling classes’.

Bernstein described the controlling classes as that part of

the middle class who act as agents of cultural production

(Bernstein, 1975). However, not all sections and cultures

within society support the set of values and beliefs held

by the controlling classes (Bernstein, 1975).

The categorisation of pupils according to their responses

to the instructional and regulatory orders

Understanding Bernstein’s categorisation of pupils is

facilitated by Bronfenbrenner’s insights into the socio-

ecological influences on human development (Bronfen-

brenner, 1989). Drawing on Bronfenbrenner (1989) and

Bernstein (1975), we propose that each pupil’s response

to the instructional and regulatory orders of the school,

and consequent involvement with the school, depends

on several factors. These include the family and socio-

cultural origins of the pupil, the pupil’s friendship

groups, the pupil’s perceived or expected future occupa-

tion, the pupil’s hopes and interests and the pupil’s view

of the purpose of the institution. Each school’s culture,

hopes, and expectations can also modify pupil involve-

ment. Bernstein believed that pupils could be categorised

as ‘committed’, ‘‘alienated’’, ‘detached’, and ‘estranged’

according to their responses to the instructional and

regulatory orders of the schools they attend.

‘Committed’ pupils understand the methods of the

instructional order and can meet its demands. They also

understand, are empathetic with, and committed to, the

aims and values of the regulatory order. These pupils are

commonly middle class.

‘Alienated’ pupils either do not understand or they

reject both the aims and methods of the instructional

order and the aims and values of the regulatory order.

These pupils are hostile to school as an institution and

are commonly working class.

‘Detached’ pupils understand the methods of the

instructional order and can meet its demands. However,

they either do not understand the aims and values of the

regulatory order of the school (commonly working

class) or understand these aims and values but do not

share them (commonly middle class).

‘Estranged’ pupils understand the methods of the

instructional order but cannot meet its demands. They

do however understand, and are empathetic with, the

aims and values of the regulatory order and are

commonly middle class.

Fig. 2 summarises pupil categories based on relation-

ships with the instructional and regulatory orders.

How do pupils’ responses to the instructional and

regulatory orders affect their ability to function while at

school?

The categorisation of pupils in Fig. 2 provides a basis

for our interpretation of how pupils’ responses to

schools may or may not promote the realisation of the

capacity for practical reasoning and the capacity for

affiliation. As has been argued, Nussbaum maintains

Understand methods of the

instructional order and are

able to meet demands

Reject or are unable to meet

demands of instructional order

Understand and committed to

values of regulatory order

Committed Estranged

Do not understand or are not

empathetic to values of

regulatory order

Detached Alienated

Fig. 2. Pupil categories based on responses to the instructional and regulatory orders (after Bernstein, 1975).

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–1220 1213

these two capacities are overarching and plan and

organise the others. They also, we propose, have the

greatest influence on a person’s health.

The aims of the instructional order, according to our

theoretical frame, are to relay knowledge and skills and

to influence pupils’ orientations to meaning, which will

influence the realisation of the capacity for practical

reasoning. When the pupil is ‘committed’ or ‘detached’,

the school has the greatest potential to facilitate the

realisation of the capacity for practical reasoning

through mastery of the learning opportunities provided

by the school. As previously outlined, Bernstein main-

tains, that these opportunities are commonly driven by

the needs of the state, the economy, and higher

education. When the pupil is ‘estranged’ or ‘alienated’,

we suggest that the potential for the school to facilitate

the realisation of this capacity is greatly reduced because

these pupils cannot engage as effectively with the

learning environment.

We also reason that the aims of the regulatory order,

which are to influence pupil’s values, will influence the

realisation of the capacity for affiliation. We propose

that when pupils are ‘committed’, the school is

supportive of, and supported by, the values of their

families and other social aspects of the pupils’ lives. The

realisation of the capacity for affiliation is, we argue,

dependent on shared values and orientations to mean-

ing. Thus, schools will promote the realisation of this

capacity when pupils are ‘committed’. This will facilitate

the creation of a socially valued identity and promote

the development of characteristics such as self-esteem.

‘Committed’ pupils are also likely to feel socially

supported, experience a sense of belonging and feel that

the cultures and institutions to which they are affiliated

are consistent and stable. ‘Alienated’ and ‘detached’

pupils are not empathetic with the values of the school.

We reason that the lack of shared values will hinder the

realisation of the capacity for affiliation amongst

‘alienated’ and ‘detached’ pupils. This will make it

difficult for these pupils to fulfil their need to create a

socially valued identity and hence develop character-

istics such as self-esteem and a sense of belonging. The

inconsistency and possible conflict between the values of

the school and those of the communities to which these

pupils are affiliated is likely to result in ‘alienated’ or

‘detached’ pupils experiencing cultural instability. ‘Alie-

nated’ and ‘detached’ pupils must develop relationships

with people who share their values in order to realise the

capacity for affiliation and, thus, create a socially valued

identity and meet their needs to feel a sense of belonging

and feel socially supported. They will, commonly,

consequently adopt the values of particular youth

culture(s) and/or remain loyal to the values of their

family, culture or local community. Bernstein main-

tained that ‘estranged’ pupils are empathetic to the

school’s regulatory order. However, their failure to meet

the demands of the instructional order is likely to

result in reduced opportunities to affiliate with a peer

group that shares their values. This is because most

pupils who share their values can, and do, meet the

demands of the instructional order and will, as a

consequence, often be in different classes. School for

‘estranged’ pupils’ is not consistent with other social

aspects of their lives. We propose that school is a

potentially damaging experience for ‘estranged’ pupils

because it could hinder the realisation of the capacity for

affiliation and, thus, the fulfilment of the needs of

‘estranged’ pupils to create a socially valued identity and

feel a sense of belonging. This is likely to affect their self-

esteem.

Pupils’ responses to the instructional and regulatory

orders, we propose, will also influence the continued

realisation of the capacities for practical reasoning and

affiliation, and thus, the potential to function well and

be healthy after the pupils have left school. This is

because the responses of pupils to the instructional and

regulatory orders will, we believe, affect what each pupil

is able to do and be as an adult.

How do pupils’ responses to the instructional and

regulatory orders affect their ability to function and

their health after they have left school?

‘Committed’ pupils have the best chance of function-

ing well and maximising their health potential as adults.

They are more likely, than other pupils, to enter higher

education, take up positions with high social status and

receive high income. Higher education will facilitate the

continued realisation of the capacity for practical

reasoning through the learning opportunities provided

within this context. Holding relatively high social status

positions is likely to increase the potential to be involved

in socially valued decision making outside of the

contexts of friends and family, which will facilitate the

realisation of the capacity for affiliation. A good income

is likely to provide adults with the time, space, and

opportunity to fully realise a number of essential

capacities including the capacity for affiliation and the

capacity to live life in one’s own context. Thus,

potentially, ‘committed’ pupils are more likely to

function well and enjoy better health after they have

left school as well as when they are at school.

Based on the same principles, we maintain that

‘alienated’ pupils are least likely to enter higher

education and hold positions of high social status.

They, therefore, need to find other avenues to facilitate

the realisation of the capacity for practical reasoning

and the capacity for affiliation. In addition, they are also

less likely to have a sufficient income. Insufficient funds

may force people to focus on their fundamental needs

such as the need for food, warmth and shelter at the

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–12201214

expense of fully realising some capacities such as the

capacity for affiliation.

‘Detached’ pupils have the potential to access higher

education, hold high social status positions and access

sufficient income. We suggest, however, that their values

may continue to differ from those of the controlling

classes when they reach adulthood. If this happens, they

are likely to look to their affiliations with alternative

cultures or family and community to promote the

continued realisation of the essential capacity to laugh

and play and the essential capacity to love, grieve, feel

longing for and gratitude. This will emphasise their non-

acceptance of the values of the controlling classes and

possible exclusion from groups of people, such as work

colleagues, who hold these values, which, in turn,

hinders the realisation of the capacity for affiliation.

Alternatively, detached pupils may choose to accept the

values of the controlling classes and reject the values of

their family and/or communities when they become

adults. The resulting conflict between their own values

and those of the people with whom they grew up will

also hinder the realisation of the capacity for affiliation.

To function well and maximise health potential, adults

in either of these situations would have to develop the

ability to understand, manage, and resolve the resulting

conflicts. This would require them to grasp the concept

of multiple realities. Alternatively, detached pupils who,

as adults, continue to reject the values of the controlling

classes, could aim to hold positions of high social status

that are not based on the values of the controlling

classes. Such positions have the potential to enable these

adults to become involved in socially valued decision

making outside the contexts of friends and family and to

work with people who are empathetic with their values.

We believe that the likelihood of ‘estranged’ pupils

taking up positions that have high social status and

accessing sufficient income is greater than that of

‘alienated’ pupils. This is because they are frequently

better connected, and understand, and are empathetic

with, the language and the necessary conduct, manner

and behaviour that is required. However, their ability to

function well as adults will depend on finding means,

commonly other than higher education, to facilitate the

realisation of the capacity for practical reasoning.

Sufficient realisation of this capacity would enable them

to understand, manage, and resolve conflicts when they

were school pupils. These conflicts arise because of an

understanding of the aims of the instructional order but

an inability to meet its demands and because of a wish to

be a valued member of a social group and the potential

exclusion from this group.

Bernstein acknowledges that schools are not homo-

geneous. Thus, a pupil’s response to the instructional

and regulatory orders will vary according to the school

he/she attends. For example, a pupil who is ‘detached’ in

one school could be ‘committed’ to another school

where the aims and values of the regulatory order are

different. Schools, therefore, have the potential to

intervene in order to promote the commitment of pupils

to the school’s instructional and regulatory orders and

offset the potential disadvantages of pupils susceptible

to becoming ‘alienated’, ‘detached’ and ‘estranged’.

How can schools promote pupil functioning and maximise

the health potential of all its pupils?

Drawing on Bernstein, the key to the potential of

schools for intervening in order to promote pupil

functioning lies in the classification and framing of the

school. Classification and framing focus on school

organisation, curriculum development and pedagogic

practice. The classification and framing of a school,

consequently, determines the school’s influence on the

learning and social experiences of pupils. Through these

arguments, we propose that the classification and

framing of individual schools will greatly influence the

realisation of the capacities for practical reasoning and

affiliation amongst pupils. Schools, we suggest, could

adopt appropriate forms of school organisation, curri-

culum development and pedagogic practice to facilitate

all pupils’ ability to function well and, therefore,

promote health. This proposal forms the basis for our

concept of health promoting schools.

How might the classification be organised in order to

promote pupil functioning?

Classification refers to the boundaries between the

school and the outside world and boundaries within the

school that occur between teachers and pupils, between

pupils and between subjects. Classification encompasses

school organisation and some aspects of curriculum

development. When the boundaries between the school

and the outside world and the boundaries within schools

are strong and well insulated the school is ‘strongly

classified’. The strength of these boundaries is the key

factor that we believe determines the relationships

between classification and health through pupil func-

tioning. However, the influences of the strength of the

various boundaries on pupil functioning and, therefore

pupil health, will, we propose, vary according to the

boundary in question.

Boundaries between the school and the outside world

According to Bernstein, strong boundaries between

school and the outside world prevent parents, the local

community, and outside agencies from being involved in

decision making within the school. These strong

boundaries ensure that the regulatory order is not

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–1220 1215

tainted by external influences and remains true to the

values and beliefs of the school, commonly those of the

controlling classes. The wider community may not share

the values of the school. In these situations, weakening

the boundaries between the school and the wider

community results in the convergence of the values,

beliefs, and interests of the school and the wider

community (Bernstein, 1975). The resulting regulatory

order would be based on more general principles rather

than being commonly directly attributable to the values

of the controlling classes. We propose that weakening

the classification by reducing boundaries between

schools and communities would promote the realisation

of the capacity for affiliation amongst more pupils. This

is because a larger proportion of pupils, particularly

those susceptible to being ‘alienated’ or ‘detached’,

would share school values as these would be based on

general principles and would, consequently, be more

likely to feel at ease with the school.

Boundaries between teachers and pupils

Pupils are prevented from being involved in organisa-

tional decision making when there are strong boundaries

between teachers and pupils (Bernstein, 1975). Increas-

ing pupil involvement in the school’s decision making

processes through, for example, staff/student councils,

can weaken these boundaries and, we propose, promote

greater insights of both pupils and staff into each other’s

realities and, thus, greater insights into the potential for

multiple realities. This would facilitate the realisation of

the capacity for practical reasoning, especially amongst

pupils susceptible to being ‘alienated’ or ‘estranged’.

Increasing pupil involvement could also promote a

greater understanding of each other’s values, which, in

turn, would facilitate the realisation of the capacity for

affiliation, especially amongst pupils who are susceptible

to being ‘alienated’ or ‘detached’.

Boundaries between pupils

Strong boundaries between pupils based on celebrated

hierarchies, such as year groups, facilitate division and

subordination (Bernstein, 1975). Bernstein (1975) main-

tained that these boundaries could be weakened through

greater communication, shared tasks, and greater co-

operation. We propose that weakening the boundaries

between pupils facilitates the development of insights

into the potential for multiple realities and, hence, the

realisation of the capacity for practical reasoning.

Boundaries between subjects

Strong boundaries between subjects occurs when each

subject is considered to be separate and to have defined

and different ways of thinking, knowledge, and skills

(Bernstein, 1996). Bernstein reasoned that when bound-

aries between subjects are strong, an ‘education in depth’

approach is adopted and learners are expected to

develop their educational identities through the acquisi-

tion of states of knowledge in individual subjects.

‘Education in breadth’, on the other hand, occurs when

the insulation between subjects is breached (Bernstein,

1996). The introduction of cross-curricular themes that

subordinate subjects breaches the boundaries between

subjects. For example, natural selection as a cross-

curricular theme could be viewed from both biological

and sociological perspectives. Bernstein (1996) empha-

sised the difference between cross-curricular themes and

a focused curriculum. A focused curriculum occurs

when the same topic is addressed in different subject

lessons which have defined and separate ways of

thinking, for example studies on smoking in mathe-

matics and biology lessons. This tends to reinforce

pupils’ understanding that each subject has distinct ways

of thinking and separate states of knowledge. Education

in breadth, in contrast, encourages pupils to develop an

understanding of ways of knowing and an under-

standing of how knowledge is socially constructed. It

also encourages pupils to view knowledge as a range of

equally valid and sometimes conflicting realities. We

believe that such an approach is more likely than

education in depth to facilitate the development of

insights into the potential for multiple realities at an

earlier developmental stage and, therefore, the realisa-

tion of the capacity for practical reasoning for all pupils

at an earlier age. Bernstein reasoned that when an

education in depth approach is adopted, most people

have to study to university level and beyond before they

sufficiently grasp the concept that knowledge is socially

constructed, or may never do so.

How might the framing be organised in order to promote

pupil functioning?

Framing refers to communication and encompasses

pedagogic practice and additional aspects of curriculum

development. As with classification, the strength of the

framing is the key factor that we believe determines the

relationships between framing and health through pupil

functioning. Different methods for weakening the

framing will, we propose, favourably influence pupil

functioning and, therefore, pupil health.

Teaching that is primarily didactic and teacher led is

strongly framed. Weakening framing by increasing pupil

input to the management of her/his own learning, and

therefore, increasing pupil input into curriculum devel-

opment can be achieved by increasing pupil choice

regarding the selection, pacing, and sequencing of

classroom activities (Bernstein, 1996). We reason that

this develops pupils’ understanding of how to manage

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–12201216

challenges and mobilise resources to cope and, thus,

facilitates the realisation of the capacity for practical

reasoning.

Increasing the contribution of pupils’ own knowledge

and skills to the learning process may also weaken the

framing (Bernstein, 1996). We propose that this can be

achieved through the introduction of pupil-centred

techniques, such as discussion groups, brainstorms,

mind maps, and role-plays. These generic tools for

‘learning how to learn’ can be used in a wide range of

situations. Their use encourages pupils to develop self-

reflective skills and to identify and understand the

origins of their own and their classmates’ orientations to

meaning, values, interests, and expectations. This facil-

itates understanding of multiple realities and, thus, the

realisation of the capacity for practical reasoning. This

type of pupil input may also promote increased under-

standing of a range of orientations to meaning and

values and, thus, has the potential to reduce the threat of

values that are not shared which would facilitate the

realisation of the capacity for affiliation.

Conclusion of how schools may promote that realisation of

the capacity for practical reasoning and the capacity for

affiliation

We have argued that weakly classified schools

promote pupils’ capacity for practical reasoning by

weakening boundaries between teachers and pupils,

boundaries between pupils, and boundaries between

subjects. Weakly classified schools also facilitate the

realisation of the capacity for affiliation, especially

amongst pupils, who in other schools would be ‘alienated’

or ‘detached’, by weakening the boundaries between

school and the outside world, boundaries between

teachers and pupils and boundaries between pupils.

Similarly, weakly framed schools facilitate the realisa-

tion of the capacity for practical reasoning by providing

students with more responsibility for their own learning

and increasing pupil input into curriculum development.

They also promote the realisation of both the capacity

for practical reasoning and the capacity for affiliation

through the greater use of pupil centred techniques and

generic tools for leaning how to learn.

A new interpretation of a health promoting school

As we have argued, health has its roots in human

functioning. The realisation of the essential capacities,

particularly practical reasoning and affiliation, are

necessary to function well. A health promoting school

then would primarily aim to promote health by

facilitating the realisation of the capacities for practical

reasoning and affiliation and, thus, pupil development

and pupils’ ability to function well. Bernstein’s insights

into school organisation, curriculum development and

pedagogic practice facilitate an understanding of how

schools may influence the realisation of these essential

capacities. We propose that health promoting schools

would be both weakly classified and weakly framed. The

resulting school organisation, curriculum development

and pedagogic practice would promote pupils’ critical

reflection, sense of belonging, sense of being socially

supported, and self-esteem and this, in turn, would

promote pupils’ health. According to our interpretation

of health promoting schools, such schools would also

aim to encourage pupils to become ‘committed’ to the

school by promoting cultural congruence between the

school and the wider community. This approach, we

believe, has the greatest potential to offer social support,

consistency and cultural stability, especially for pupils

who are susceptible to being ‘alienated’, ‘detached’ or

‘estranged’. Antonovsky (1987) also highlights the

influence of ‘generalised resistance resources’ including

social support, consistency and cultural stability on the

promotion of health. From an educational perspective,

health promoting schools would adopt an education in

breadth approach which facilitates greater pupil input to

the management of their own learning and greater use of

pupils’ knowledge and skills. By greater pupil input, we

do not, however, mean peer led education, such as has

been observed in some smoking and sexual health

interventions (Bloor et al., 1999; Mellanby, Phelps,

Crichton, & Tripp, 1995; Mellanby, Newcombe, Rees, &

Tripp, 2001). Adolescents involved in interventions such

as these, are often selected on the basis of popularity or

perceived maturity and, as highlighted by Milburn

(1995), primed to deliver adult messages. In practice,

we suggest two major aims of health promoting schools

would be to increase partnerships between the schools

and parents and to increase community involvement in

the decision making processes of the school. Achieve-

ment of these aims would be facilitated by inter-sectoral

collaboration between the school and statutory and non-

statutory agencies that have close working relationships

with the community. Another major practical aim of

health promoting schools would be to encourage wider

pupil involvement with each other and with the decision

making processes of the school. This aim is consistent

with the views of Jensen, Schnack, & Simovska (2000)

regarding the importance of ‘action competence’. How-

ever, as they maintain, token pupil representation

without interventions that facilitate the development of

pupil confidence and pupil skills is unlikely to encourage

pupils to take responsibility for generating change

though the conversion of their own ideas into action

plans and positive outcomes (Jensen et al., 2000).

We acknowledge that strongly classified and strongly

framed schools may have very ‘committed’ pupils

especially when such schools select pupils, for example

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–1220 1217

by academic attainment. Schools that operate a strict

selection process are, almost by definition, fully sup-

ported by pupils’ families who share the values of the

schools and are often supported by the wider commu-

nity as well. Pupils at these schools will feel socially

supported, a sense of belonging and experience cultural

stability. They will, therefore, probably have enhanced

self-esteem and be likely to be functioning relatively

well. Furthermore, these pupils will often have greater

opportunities to function well as adults. However, even

in these usually advantaged circumstances, weakening

the classification and the framing would, we believe,

further promote pupil functioning by facilitating greater

understanding of multiple realities and, thus, elaborate

orientations to meaning. This, we surmise, would

facilitate even greater realisation of the capacity for

practical reasoning.

According to our theory, health promoting schools

would also ensure that some fundamental human needs

are met concerning non-useful pain and information

about the body (Table 1). Anti-bullying initiatives are

required to prevent non-useful pain. Pupils who feel that

their personal security is continuously under threat may

take time off school, which could hinder the realisation

of the capacities for practical reasoning and affiliation.

We propose that anti-bullying interventions would have

the greatest potential to promote health when they are

based on the principles of weakening the classification

and weakening the framing highlighted above. In

practice this would involve pupils in the choice of the

focus of the intervention and in all stages of the

planning, implementation and evaluation of the initia-

tive. We also acknowledge that health promoting

schools should provide information about the body.

However, the provision of this information should also

be based on the principles of weakening the classification

and weakening the framing that we highlight. Thus,

information about the body should be a cross-curricular

theme rather than provided solely within the contexts of

health education and biology lessons. The use of

‘learning how to learn’ techniques should also be

employed in order that pupils come to understand their

own values and expectations regarding the body.

Hypotheses generated from the new interpretation of

health promoting schools

The key issue regarding theoretical frames is whether

they have explanatory power in addition to being able to

describe. The validity of our new theory of health

promoting schools could be investigated through the

testing of the following examples of hypotheses that

have been inductively derived from the theory.

First, while attending school, ‘committed’ pupils

would enjoy better psychological health outcomes

than pupils who are ‘alienated’, ‘detached’ or ‘es-

tranged’.

Second, ‘committed’ pupils would also enjoy more

favourable psychological well being, psychological ill-

ness outcomes and physical health outcomes in adult life

than ‘alienated’, ‘detached’ and ‘estranged’ pupils.

Third, a greater proportion of pupils would enjoy

favourable psychological well-being outcomes in weakly

classified and weakly framed schools than in strongly

classified and strongly framed schools when both types

of schools have equivalent pupil populations. Equiva-

lence would be based on socio-cultural origins of the

pupils.

Fourth, schools that meet the following criteria would

promote pupil health and well-being. First, they would

actively promote the involvement of the local commu-

nity and pupils in the decision making processes of the

school. Second, they would have a teacher with a

designated responsibility for ensuring that cross-curri-

cular themes were taught in each school year and across

pupil attainment levels. Third, they would actively

promote the involvement of pupils in the development

of the curriculum. Fourth, they would actively promote

the use of learning ‘how to learn’ skills. This criterion

could be met, for example, by encouraging teachers to

adopt the principles and practice of the University of the

First Age initiative (Burgess, 2000).

Comparisons with other interpretations of health

promoting schools

As indicated in the introduction, our interpretation of

health promoting schools resonates with the eco-holistic

model of health promoting schools developed by

Parsons et al. (1996). Both models highlight the need

for increased community and pupil involvement with the

decision making processes of the school and focus on the

formal curriculum. Our views are also supported by

relevant WHO documentation. For example the WHO

European Office definition of health promoting schools

indicates that in order to promote health, schools should

focus on their management structures, internal and

external relationships and teaching and learning (WHO,

1998). While Tones (1996), drawing on the Ottawa

Charter, maintains that the best defence against disease

and premature death is the empowerment of people. Our

interpretation is also consistent with Baric (1992, 1993)

who reasoned that in order to be health promoting,

organisations such as schools should focus on their

organisational systems and peoples’ interactions within

the organisation.

There are, however, differences between our inter-

pretation of health promoting schools and other

commentators’ interpretations. First, we focus on pupils

and their families rather than adults working in the

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–12201218

schools. Second, unlike the WHO which asserts that

there is a two-way relationship between health and

education our model states that education facilitates the

ability to function well and this ability is the basis of

good health. Third, unlike other related theories, the

new theory has the potential to offer insights into the

relationships between school experience and adults’

health and to predict which pupils will enjoy the best

health while they are at school and after they leave

school. Fourth, we reason that there is no requirement

for the allocation of specialist health education and

health promotion roles to teaching staff or a require-

ment for inter-sectoral collaboration with outside

agencies with a specialist remit for health, unless that

is, these agencies can help facilitate community involve-

ment with the school. Fifth, we believe that cross-

curricular themes should be encouraged whenever

possible and should not focus solely on topics that fall

under the traditional health education remit such as

information about the body. For example, Denman,

Moon, Parsons, and Stears (2002) describe a health

promoting school that had thematic weeks on topics

such as communication skills and good manners. Sixth,

according to our interpretation, schools do not need a

formal health education curriculum that aims to prevent

individuals from adopting behaviours that increase their

chances of developing chronic disease in adulthood in

order to be health promoting. However, when English

schools do have designated health education lessons,

they should capitalise on the non-mandatory nature of

the health education curriculum. Currently, such lessons

often focus on healthy lifestyle choices and the devel-

opment of individual skills, such as assertiveness, to

resist social pressure to make unhealthy lifestyle choices.

We believe health education classes should instead,

focus on the development of the skills necessary for

collective action. This, we reason, would facilitate the

realisation of the capacity for affiliation. Disenfran-

chised pupils or adults who become disenfranchised

after leaving school could perhaps use these skills to

break the seemingly unbreakable links between social

disadvantage and psychological well being, psychologi-

cal illness and physical health.

Conclusion

This paper proposes that the application of our

analysis of Nussbaum’s Aristotelian interpretation of

human functioning to Bernstein’s theory of cultural

transmission outlines a potentially helpful explanatory

frame for understanding schools as health promoting

organisations. This outline indicates how school orga-

nisation, curriculum development and pedagogic prac-

tice may be advantageously implemented to promote

pupil health by facilitating the realisation of the

capacities for practical reasoning and affiliation and

thus, pupil development and pupil functioning. Our

notion that health promoting schools are weakly

classified and weakly framed (Bernstein, 1975) is explicit

about the underpinning values and theoretical base.

Testing the generated hypotheses would ground the

theory in an evidence base and may potentially lead to

improved understanding of the relationships between

the postulated key concepts and health. This, in turn,

could lead to improvements in the planning, implemen-

tation, and evaluation of future health promoting school

initiatives. Research validation is required before our

suggested approach is accepted. However, the great

benefit of this theory is that it does offer a range of

testable hypotheses. In addition, it has three potential

advantages at the policy and intervention levels. First, a

greater proportion of the teacher workforce could

potentially be informed about our theory and the

postulated health benefits of schools which is likely to

positively impact on policy implementation. This is

possible because Bernstein and Nussbaum are already

extremely influential in the field of education. The only

additional requirement would be to highlight the

relevance of their insights to health. Thus, our theory

is more likely than existing theories to be incorporated

into the mainstream teacher training/education sylla-

buses of higher education institutions and into in-service

training and continuing professional development train-

ing syllabuses in higher education institutions. Cur-

rently, existing theories of health promoting schools

tend to be disseminated primarily to trainee teachers and

teachers with a special interest in health promotion.

Second, the UK health promoting schools initiative is

heavily influenced by government policy that primarily

equates health with healthy lifestyles. However, a central

plank of the current UK government policy focuses on

reducing social exclusion. The new theory could draw on

the social exclusion aspect of government policy and,

potentially influence the direction and purpose of the

health promoting school initiative in the UK. Perhaps

the greatest drawback to the adoption of the new theory

is the predominant belief, particularly in UK univer-

sities, that education in depth is preferable to education

in breadth. However, the continuing popularity of

courses such as gender studies and media studies indicates

that this view may not be as entrenched as it once was.

Third, our theoretically based approach provides a basis

for understanding why some health promoting school

interventions seem to have been successful and others,

perhaps with a different emphasis, appear to have failed.

Acknowledgements

We are very grateful to Rita Jordan for her

encouragement and willingness to debate the contents

W.A. Markham, P. Aveyard / Social Science & Medicine 56 (2003) 1209–1220 1219

of this paper. We would also like to thank Alison

Bullock, Vickie Firmstone and Harry Daniels.

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