Dharamsi S, Woollard B, Okullo I, Kendal P, Macnab A. Health Promoting Schools as Learning Sites for Physicians In-Training. Health Education. 2013;114(3):186 – 196.

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Abstract:

Purpose - Although medical schools do well in preparing the next generation of practitioners to diagnose and clinically treat illness, they struggle in preparing them with capabilities in the areas of health promotion and disease prevention. Similarly, health promoting schools face challenges in working to enhance the health and educational outcomes of children. Design/methodology/approach – The authors draw from their local and international collaborative work as practitioners and medical educators to examine how health professions schools can work in partnership with health promoting schools for mutual benefit. Findings - Health advocacy is a core competency in medical education. A primary focus is on health promotion and disease prevention. However, providing practical, experiential opportunities – ‘learning-by-doing’ – is a challenge. To overcome this difficulty, medical schools may be well served by partnering with health promoting schools. This can provide mutually beneficial learning opportunities that will enable emerging physicians to develop health promotion related knowledge and advocacy skills while the emerging generation of citizens (our children) are enabled to live healthier and more productive lives. Originality/value – The parallel development of Health Promoting Schools and the teaching of health advocacy to health professionals has proceeded to the point where convergence of the gathered knowledge and experience can provide a powerful and synergistic model to advance both initiatives. This conceptual paper focuses outlines the actions that might achieve this. Keywords: Health, Advocacy, Children; Health Promotion, Schools; Medical Schools; Accountability

Dharamsi S, Woollard B, Okullo I, Kendal P, Macnab A. Health Promoting Schools as Learning Sites for Physicians In-Training. Health Education. 2013;114(3):186 – 196.

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Article Classification: Conceptual Paper Background Health and learning are inextricably linked. The World Health Organization’s Global School Health Initiative was developed as a cost-effective way to simultaneously improve outcomes in both education and health through the concept of Health Promoting Schools (HPS). The aim is to help address health and social disparities in socioeconomically disadvantaged areas around the world where national resources for both health and education are sparse. It is an approach that seeks to respond to important health risks that impact school children and to involve the education sector in efforts to influence the educational, social, economic and political conditions that affect health outcomes. Health promoting schools can contribute to improved school attendance and performance, and enhance children's independence, strength, capacity and psychosocial resilience. Longer-term benefits may also accrue to the larger community, with the potential for significant impact on the overall health and educational well-being of socioeconomically vulnerable populations who have poor access to both adequate healthcare and education. In November 2011 an international colloquium on Health Promoting Schools was held at the Stellenbosch Institute of Advanced Study in South Africa, as described in the paper by Macnab et al in this special edition. Forty participants (policy makers, pediatricians, family physicians, social scientists, and educators) from various countries across five continents (Africa, Asia, Australia, Europe, and North America) were gathered to deliberate on how best to address health and social disparities in socioeconomically disadvantaged areas around the world using the HPS model. Work on HPS has historically been done by either university faculty or educators, but rarely with them working together, and never, to our knowledge, with direct input from community-based organizations and government policy-makers from health, education and social development sectors. Key outcomes of the colloquium were a global consensus statement and a series of articles for publication. The approach of this paper This article presents our particular contribution to the colloquium, drawing extensively from our collaborative work as medical educators charged with the responsibility to prepare future physicians to promote health and prevent disease, to be mindful and responsive to the healthcare challenges faced by vulnerable and marginalized populations, and to address disparities in healthcare and health outcomes. We first highlight the challenges and opportunities within health professions education to train the next generation of practitioners to respond to inequities in health. This is followed by an examination and examples of how to build purposeful linkages between health promoting schools and health professions schools. The related literature is also reviewed. Health Professions Education: opportunities for bridging to solutions Healthcare systems around the world face a number of challenges related to the social determinants of health, scarce resources, the delivery of health services, and access to care, all of which raise important questions concerning the education of health professionals (Frenk et al., 2010). These questions relate not only to the nature of graduates that are produced but the priorities and responsibilities of the medical schools themselves, institutions that are almost universally well resourced relative to many comparable social institutions. Frenk and colleagues build upon a

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growing call for medical schools to be more socially accountable (Global Consensus for Social Accountability of Medical Schools, 2010; Boelen and Woollard, 2009; Woollard and Boelen, 2012). The question of how to better educate future physicians to respond effectively to inequities in health and healthcare is one of the most pressing and challenging issues facing medical educators today (Cooke et al., 2006; Skochelak, 2010).

Although medical schools generally do well in preparing students in the biomedical sciences and in the recognition, diagnosis and clinical treatment of illness, there is growing concern that medical education does not adequately prepare emerging physicians to respond to the non-biomedical influences on health (Holtz et al., 2006; Rego and Dick, 2005), the priority health care needs of the communities they serve (Oandasan et al., 2004; Steiner et al., 1999; Rubenstein et al., 1997), nor the health of vulnerable and disadvantaged populations (Blumenthal and Boelen, 2001; McCally et al., 1998; Goodwin, 2007). Persistent requests are emerging to better prepare future physicians to be community and socially responsive (Brill et al., 2002; Peabody, 1999; Smilkstein, 1990). Medical schools are now paying increasing attention to social accountability (Woollard and Boelen, 2012; Boelen, 2002; Boelen and Woollard, 2009; Pálsdóttir et al., 2008), and seeking to establish standards to direct their education, research, and service activities towards addressing the priority health concerns of society (Boelen et al., 2012). This is also seen as an attempt to animate the social contract between medicine and society (Verma, 2005; Parboosingh, 2003), and to prepare emerging physicians to meet medicine’s responsibility to society by being more helpful and civic minded (Whitcomb, 2007). To this effect, the Royal College of Physicians and Surgeons of Canada provides a framework of core competencies – a set of observable knowledge, skills and attitudes – that have been integrated into accreditation standards, training objectives, evaluations, and certification (Frank and Danoff, 2007). The framework has been adapted and adopted internationally. Competencies related to the physician’s role as an effective collaborator, communicator, and health advocate introduce relatively new skill sets for physicians (Frank and Langer, 2003). The health advocate related competencies are particularly designed to prepare emerging physicians to develop their capabilities in health promotion at the individual patient level as well as the societal level with a particular focus on the social determinants of health inequalities - the range of social, cultural, economic, political and environmental circumstances in which people are born, raised, live and work and the systems in place to help them address illness (Marmot, 2005). Health advocacy is work that healthcare professionals do in response to these “non-medical” determinants found outside the healthcare system that negatively influence health outcomes. It moves beyond just working at the level of the individual patient providing counselling on matters related to healthy lifestyle. It requires working at various levels to address the root causes of illness and inequities in health (Earnest et al., 2010). Healthcare systems and educators face many recognized challenges in the training of future health professionals, but there are also under-utilized opportunities. HPS are being shown to serve as a place where future physicians and other health professionals can indeed learn about and enact their role as health promoters. In addition, the institutional relationships between health professional schools and HPS show promise of helping to re-orient both. There are important opportunities for a

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partnership between educators in centers of higher learning and HPS. For example, the HPS in Uganda is being spearheaded by the Uganda Ministry of Education and Sports (MoE&S). The MoE&S developed a School Health Policy in 2008 under the theme “A healthy mind in a healthy body for better educational performance”. The production of the School Health Policy was an effort of the MOE&S and MOH with the participation of other key stakeholders which contributed to the identification of priority areas for the promotion of health in school in order to optimize educational achievement of learners. The HPS concept requires teachers, among other actors, to operate in a number of areas in addition to classroom-based curriculum implementation, such as developing appropriate school health policies, enhancing the social environment, and linking with relevant community agencies. The success of HPS largely depends on school teachers' understandings of the building blocks of the HPS and their capacity to implement it. In Uganda however, the program has been hampered by inadequate training for the teachers and limited resources for health promoting activities. The Uganda higher education system has helped produce a high number of graduates with various degree certificates. Despite the numbers, there is an enduring need for graduates who can address the challenges and needs faced by the country more practically. Makerere University College of Health Sciences shifted from content and exam orientation to a problem-based and service-learning approach, which promotes development of critical thinking, problem solving, self-regulation and civic responsibility. Service-learning is an educational approach which expands the experiential link between training institutions and the communities. It promotes civic and moral development of the trainees and stakeholder engagements in finding timely solutions to challenges. This is one way to bridge the mutual quest for improving the health and wellbeing of society, not only through the activities of the graduates that are produced in both settings, but by the seriousness with which the respective institutional cultures approach their social accountability. In the case of Uganda noted above, explicit objectives are formulated to ensure graduates have both the will and the capacity to be effective health advocates:

• To enable future healthcare providers acquire skills to positively influence the psychosocial development of the child.

• To equip the future healthcare providers with community engagement skills. • To equip the future healthcare providers with necessary skills for health promotion and

disease prevention. • To equip the future healthcare providers with skills for school health promotion • To advance health promoting activities among school communities

Building a different future Many emerging and practicing physicians believe that health advocacy plays an important part in healthcare. A recent study of medical residents, physicians and educators that examined what inspires them to engage in health advocacy reveals that this commitment is stimulated by an early exposure to social injustice, positive role models and parental values (Mu et al., 2011). While these exposures have generally been serendipitous, the rising complexity of urban societies, increasing inequities in those societies and the increasing knowledge that something can be done about them

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calls on educators at all levels to act in a way that does not leave them to chance alone. Medical schools must provide protected time and resources, provide experiential learning opportunities and help foster a community of practice as ways to enable “learning-by-doing” health advocacy work. Yet, the health advocate capability is still regarded by educators as one of the more difficult roles to teach and to integrate effectively into medical education (Oandasan, 2005; Oandasan and Barker, 2003). To help medical educators move beyond this difficulty we recommend using Boyer’s work on “engagement” that suggests a collaborative and reciprocal partnership with social organizations in civic engagement (Boyer, 1996). Teaching, learning and scholarship around health advocacy requires a participatory pedagogy, working collaboratively with communities in the production of knowledge based on locally-identified priorities (Dharamsi et al., 2010a). To this effect, community service-learning has grown to be a robust approach directed specifically at enhancing learners’ knowledge and skills for addressing the social determinants of health, health promotion, principles of social justice and advocacy (Seifer, 1998). Medical accrediting bodies now require medical schools to make available opportunities for service-learning activities. Moving health education outside of the classroom walls and into community settings places students into everyday social practices and public participation, thereby creating opportunities for transformative learning. It provides students with deeper and more meaningful insights into public challenges, the responses to which are then appropriately conceived in the trenches of reality instead of the theoretical towers of higher education. In a study by Dharamsi and colleagues (Dharamsi et al., 2010b) of a newly developed and implemented community service-learning (CSL) option in an integrated medical/dental curriculum, the authors learned that many students felt that didactic courses addressing the social determinants of health had little practical significance to them. The CSL option appeared to provide students with a stronger sense of social responsibility and a clearer sense of how to respond to the inequities in healthcare and the priorities of those people in society who are rendered vulnerable because of various social, economic, political, environmental and biological influences that prevent them from protecting their own needs and interests. These opportunities seem to demonstrate to the students that addressing the determinants of health in the context of their professional work is not only desirable but also doable. In Uganda, for example, Community Based Education and Service (COBES) is the type of innovation that seems to be helping achieve the desired outcomes in training future practitioners for their role as health advocates. COBES enables:

• An interdisciplinary and comprehensive contribution to health care by using a community internship placement model from all the four training programs of Medicine, Dentistry, Nursing and Pharmacy;

• Integration of the National priority and strategic programs as part of clinical training; • Empowerment of Families and individuals to participate in their own health care and health

promotion; • Implementing Community directed home-based and school based health models; • Effectively implementing Primary Health Care (PHC); and • Enhancement of human resources capacity and utilisation in the Districts.

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HPS and Health Professions Schools: building purposeful linkages Partnerships between HPS and health professions schools can nurture a mutual commitment to social justice and promote the ideals of what it means to be a socially and community responsive institution. Purposeful linkages can also enable engaged scholarship through action research – an area of growing interest in higher education (Kemmis and McTaggart, 1988). Key to the success of such partnerships will be mutual dedication and commitment to sustained engagement. This can lead to positive outcomes for HPS and can also meet the evolving civic engagement aspirations of health professions schools with respect to teaching, research and service (Ostrander, 2004). It is increasingly clear that community service-learning, social action projects, and other deliberative active-learning approaches provide pathways for exploring how to better educate future health professionals to be socially responsive and socially accountable (Boelen and Woollard, 2011; Kahne and Westheimer, 2001; Schön, 1987). There is also increasing evidence that health promotion undertaken in the school setting appears to provide an awareness among children of the importance of healthy lifestyles and develops behaviours that benefit health and wellbeing of the children involved. The history, evolution, and concepts underlying health promotion in schools, the factors that contribute to success or failure, and processes to document impact are well described (World Health Organization Expert Committee on Comprehensive School Health Education and Promotion, 1997; Lister-Sharp et al., 1999; Moon et al., 1999; Stewart-Brown, 2006; Inchley et al., 2007; St Leger et al., 2009; World Health Organization, 2009). HPS initiatives combine a range of complementary approaches in the context of everyday life directed towards knowledge and action that enable individuals and school communities to increase their control over determinants of health, and contribute to their resilience and wellbeing (St Leger, 2001; Davidson et al., 2007; World Health Organization, 2009). Schools that follow the WHO HPS model have shown that through effective community collaborations and student activities, they can not only positively impact the individual children in the school, but also benefit the broader community. In addition important educational opportunities are also afforded to those initiating, delivering, evaluating and sustaining effective HPS programs (Macnab, 2013). Higher institutes of learning can easily complement their curriculum development by creating structured learning opportunities that empower and engage teachers and learners through effective involvement in HPS projects. Unique learning opportunities exist:

• identifying health promotion priorities in communities, • experiencing the dialogue necessary for initial teacher and pupil engagement, • exposure to the attitudes and priorities of children, • recognizing the importance of collaboration and support of the HPS community, and • exposure to the rich forum that evaluation of HPS projects affords.

At UBC a group of students and faculty benefited from incorporating HPS experience as a component of an initiative to address a recognized deficit in curriculum content in global health and effective exposure to community-service learning (Yeong et al., 2012). Pre- and post-evaluation of the impact of participation in HPS program delivery on students training as physicians and dentists identified novel knowledge and skill acquisition, an increased interest in global health issues, and a

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greater understanding of the determinants of health and the needs of children and families (Macnab et al., 2010; Yeong et al., 2012). Students benefiting in this way also collaborated with faculty effectively to drive curriculum change. Postgraduates graduating as paediatricians reported that experience gained during HPS initiatives in Aboriginal communities during their training had positively influenced their career choices and desired scope of practice (Macnab et al., 2011). The program developed in Canada provided a template, in partnership with Uganda institutions to develop a similar experience for students (both Canadian and Ugandan) in Uganda. Medical trainees reported that international HPS participation provided opportunities to gain competencies identified as required by their professional body (Verma, 2005) that they had not acquired in their home program (Moodley et al., 2012). Overall HPS engagement compared favourably in terms of increasing community advocacy and social responsibility to community-based rural service and learning rotations in other countries (Worley et al., 2000; Kasangaki et al., 2012; Ibiyemi et al., 2013). It is clear that the learning that occurs in the context of HPS is a ‘two way street’ and that HP schools ‘teach’ a range of valuable lessons to the members of the teams that initiate, deliver, evaluate and sustain them

Universities can also become ‘health promoting’ schools themselves by adopting the concept of healthy settings and whole system synergies (Dooris, 2006). A programme for instance to address an issue such as increasing physical activity can be developed to include all or a range of relevant components within the system (e.g. transport infrastructure, campus buildings and design, curriculum, and timetabling), and also explore interconnections with other interventions with the aim of achieving ‘multiplier effects’. It has been recognized that the opportunities that HPS create also provide common ground for alliance between unconventional health and education partners (Vergnani et al., 1998). Such ‘collaboration across sectors’ is demonstrated by the intersectoral cooperation of agencies and ministries at a regional and national level where HPS activities have been broadly promoted or networks developed to support HPS programs (Swart and Reddy, 1999; Lister-Sharp et al., 1999; Wyn et al., 2000; Stewart et al., 2004; Lee et al., 2007; Inchley et al., 2007).

Practical implications and value The rise of Health promotion Schools (HPS) at the same time that the social accountability of medical schools is gaining recognition and action provides a historic opportunity for the two trends to converge with synergistic effect on the nature of both schools and their graduates, together having a positive effect on the health of populations. Experience and studies from around the world re-enforce the likelihood that a thoughtful collaboration between health professional training schools and HPS in their communities will have three intertwined positive effects:

1. Health promoting school graduates are likely to be healthier citizens with attitudes and skills that will help to make their communities and fellow-citizens healthier in the long run.

2. Health professional schools are likely to produce graduates who are more effective advocates and actors to improve the health of the populations they serve.

3. Both levels of schools will become more carefully attuned to the needs of their societies and will be better prepared to help address those identified needs.

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In short, they will rise to the highest purpose of educational institutions in democratic societies. The co-creation of better and healthier citizens and professionals is a worthy undertaking, with a high likelihood of success.

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