Schools as a setting: the
The European Network
of Health Promoting
Schools an alliance of
health, education and
democracy
Vivian Barnekow Rasmussen and
David Rivett
The authors
Vivian Barnekow Rasmussen and David Rivett
together form the Technical Secretariat for the European
Network of Health Promoting Schools. They are based at
the World Health Organisation Regional Office for Europe,
8 Scherfigsvej, DK-2100 Copenhagen, Denmark.
Keywords
Health, Schools, Health education
Abstract
Operating within the ``settings'' approach of the Ottawa
Charter, the European Network of Health Promoting Schools
has, since its launch in 1992, been the most powerful
catalyst for the development of the health-promoting school
concept across Europe. Founded on a partnership between
the European Union, Council of Europe and the World Health
Organization, it is now established in 40 countries right
across Europe. Its principles have been determined by a
range of key meetings, conferences and documents, while
the evaluation of its practice increasingly suggests that it is
highly effective. The network is based on the principles of
empowerment, partnership, democracy, equity, action
competence and sustainability, and sees key areas for action
as being teacher education, links with parents and the
community, and evaluation, to move health promotion in
schools on to a sound evidence base. Targets for the future
development of the network include extending it to the few
remaining countries that still fall outside it, and the
widespread dissemination of its learning and goals, so that
every child in Europe can have the benefits of being
educated in a health-promoting school.
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Health Education
Volume 100 . Number 2 . 2000 . pp. 6167
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61
health-promoting school concept
The notion of the health-promoting school
dates back to the 1980s, where the question of
the effectiveness and value of school health
education was raised at a series of meetings
and workshops taking place in the UK and in
other European countries. The necessity for a
true collaboration between the health and the
education sector was recognised as being
crucial for the development of a concept
which defined the health-promoting school.
Definitions were drawn up but the Ottawa
Charter (WHO, 1986) for health promotion
provided the agreed framework for the
development of settings for health. The
charter identifies the settings in which people
live, work and learn as places where health is
created and sustained, through the creation of
supportive environments in which people can
care for themselves and others and have
greater control over their life circumstances.
The Ottawa Charter determines five areas
for action:
(1) Building healthy public policy.
(2) Creating supportive environments.
(3) Strengthening community action.
(4) Developing personal skills.
(5) Reorienting the health services.
Schools were one of the settings identified as
key to public health. The school environment,
curriculum and surrounding community are
potentially a powerful catalyst for the creation
of health for the total school population, by
developing supportive environments
conducive to the promotion of health and
assisting young people, during formative
periods of their lives, to gain deeper
understandings about how health is created
and sustained.
Seven years of growth and
development
The principles of the European Network of
Health Promoting Schools (ENHPS) are
rooted in the Ottawa Charter. The network
was launched, after the successful piloting
phase, in 1992, since which time the schools
involved have provided countless examples of
putting areas of the Ottawa Charter in action.
Schools which have created and implemented
 The European Network of Health Promoting Schools
Vivian Barnekow Rasmussen and David Rivett
health-promoting school policies, improved
their physical and social environments, and
ensured that the school health services have
been improved to take account of the health-
promoting school concept. Schools have
moved closer to their communities, and
strengthened the teaching of life skills through
the taught curriculum.
International partnerships
One of the unique features of the ENHPS is
the level of collaboration involved, and none
more so than the fundamental collaboration
on which it is founded, namely that between
the European Commission, the Council of
Europe and the WHO Regional Office for
Europe (Barnekow Rasmussen 1996a, 1996b,
1997). To date, this collaboration, which
after eight years of work is now more like a
partnership, has proved to be of immense
benefit, not only to the individual
organisations, but also to the ENHPS. The
partnership has both a financial aspect and,
and perhaps more important, a political one.
By the three organisations working together,
sharing resources, espousing the same
message and acting as advocates for young
people's health at a high level in Europe, the
profile of health promotion in schools has
been greatly enhanced.
The three organisations work together to set
the broad course for ENHPS, to mobilise
resources and to access technical expertise
from within their own structures. Through
the network, each organisation is able to
pursue their own goals of developing health,
unity and human rights. To manage the
partnership, the International Planning
Committee (IPC), made up of representatives
from each organisation, meets regularly to
facilitate the growth and development of the
ENHPS and steer its strategic direction.
Other vital partners in the development of the
network include European institutions, other
UN agencies with common goals,
philanthropic organisations, WHO member
states and two WHO ENHPS collaborating
centres that supply staff, time and expertise.
It is the aim of the network to not only seek
collaboration but to also generate sustainable
relationships with those who become
involved, so that the work of the network
becomes the work of all key players and a
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strong bond of ownership is created. The
work to increase ownership and partnership is
ongoing, and in some cases in its infancy, but
the sustained relationship between the three
principal European organisations provides a
model from which developments are being
made.
The Technical Secretariat at the WHO
regional office provides vital support to the
IPC, the national co-ordinators in
participating countries, those involved with
the daily co-ordination and administration of
ENHPS, and participating schools. One of
the secretariat's functions is to hold annual
business meetings of national co-ordinators.
These meetings provide an essential forum for
communication and co-operation between
the co-ordinators, the IPC and the Technical
Secretariat. The secretariat organises
workshops, seminars, meetings and training
events for the co-ordinators and national
teams: topics have included information and
media skills, the training of trainers, project
management and evaluation. In addition,
secretariat staff offer general advisory support
and make country visits to help set up or carry
out network activities. They also help to bring
new members into ENHPS.
Joining the ENHPS
All member countries belonging to the three
sponsoring agencies are eligible to join the
network, and there are thus 52 potential
members in total. Over the past seven years,
the network has grown steadily and currently
40 countries make up the membership. For
countries to participate, certain prerequisites
for membership are required. These are:
. A signed agreement of collaboration
between both ministers of health and
education.
. A management structure for the country
networks, which should include a
national co-ordinator and a centre for
co-ordination.
. An agreed three-year programme and a
network of pilot schools.
Pilot schools should be able to introduce and
innovate ideas and thinking around criteria
that characterise a health-promoting school
(ENHPS Technical Secretariat, 1999).
Evaluation should take place to ensure that
 The European Network of Health Promoting Schools
Vivian Barnekow Rasmussen and David Rivett
learning from pilot schools is gathered, to feed
into a national dissemination strategy, and
this should be a planned ultimate objective of
the programme. These criteria were agreed at
international level at the very start of the
process and have been developed further and
refined at both national and local level
according to the needs of countries and
schools.
From a strategic point of view, the initiative
has been an impressive success. As one of the
largest international networks of its kind, it is
a unique example of collaboration between
three European organisations, within
countries between the Ministry of Health and
Ministry of Education and local level
partnerships between schools and local
communities. The network is gaining in
prestige as it becomes more understood by
those outside the programme.
Resources for the ENHPS
The first phase of the ENHPS project focused
on developing activities suited to the needs
and circumstances of each participating
school, and sharing the results with others.
The networks in countries comprised a
number of pilot schools which were guided by
the national teams and international
developments in the development of their
health-promoting school initiatives.
In addition, the Technical Secretariat set
about preparing a range of resources to assist
these developments. Purposely, the Technical
Secretariat has not developed classroom or
curriculum resources, rather a number of
co-ordinator and teacher-training manuals
have been commissioned and in some cases
collaboration has been developed between
other agencies and co-publications have been
produced as a result.
Publications have included a resource
manual for co-ordinators (WHO, CEC, and
CE, 1993), manuals for both elementary and
secondary schools in the development of their
early steps in the creation of health-promoting
school initiatives (Metcalfe et al., 1995;
International Planning Committee of the
European Network of Health Promoting
Schools, 1995) and a manual which provides
guidance on how to evaluate health-
promoting school activities (Piette, 1995).
Some projects, such as the ENHPS Mental
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and Emotional Health initiative have
produced both manuals and associated
teacher education programmes (Weare and
Gray, 1995). Furthermore, pilot projects at
national level and in schools have generated a
vast body of experience that has formed the
basis for the second phase of the ENHPS.
Through all such initiatives, both health and
education policy and practice has
demonstrably been influenced throughout
Europe (Parsons et al., 1997).
The ENHPS development plan
Following the official agreement of the
European Commission, the Council of
Europe and WHO Regional Office for Europe
to jointly launch and support the European
Network of Health Promoting Schools in
1992, among the significant landmarks we
particularly note the following.
The ENHPS Development Plan 1996-2000
(WHO, 1997a). The plan, drawn up though a
collaborative process involving the
international organisations, the Technical
Secretariat and the ENHPS national
co-ordinators, provided direction for the
second phase of the project. Its goals were the
fostering of an increased degree of
commitment to the concepts and principles of
the health-promoting school among the key
partners (schools, communities, health and
education sectors, governments and others)
and to influence key policy and decision
makers. The major focus of the development
plan was the implementation and
dissemination of the concept as well as
research and evaluation. Based on the
experience drawn from the first phase of the
ENHPS process, a range of activity areas were
identified to be of key importance. They
included the involvement and commitment of
all agencies involved through co-ordination
and networking, the need to make the
transition from pilot to policy, the importance
of training, and the mobilisation of
resources.
Thessaloniki: the first ENHPS
conference
A highly significant step for the ENHPS was
the first conference of the European Network
 The European Network of Health Promoting Schools
Vivian Barnekow Rasmussen and David Rivett
of Health Promoting Schools: ``The health
promoting school an investment in
education, health and democracy'', held in
Thessaloniki, Greece, in May 1997.
Participants from 43 countries attended,
including policy-makers and
parliamentarians, parents, teachers and other
experts in education, health professionals,
representatives of international bodies and, of
course, young people themselves. The
participants, many for whom the notion of the
health-promoting school was relatively new,
met to gain a deeper understanding of the
progress of the network, to share their
experience, assess their achievements and
discuss the most effective means of
influencing education policy and practice
throughout Europe.
The conference used a variety of methods
to encourage the broadest and most
productive participation. Case studies from
across Europe were a key mechanism for
generating and actively involving all the
participants in discussion (ENHPS Technical
Secretariat, 1997). The case studies covered a
diverse range of issues, including:
. Teacher training and curriculum
development.
. Using the school as a setting for health
promotion.
. Collaboration with parents and the
community.
. School policy development.
. Pupils as active partners.
. Evaluation.
. International co-operation.
. Democracy, management and
organisational change.
The work of the conference led the
participants to draw conclusions and make
recommendations, which were recorded in
the conference report, and which continue to
be placed in front of policy and decision
makers (WHO, 1997b). We will summarise
them briefly below.
The conference agreed that certain key
principles need to underpin the health-
promoting school movement, they are:
democracy, equity, sustainability,
collaboration and empowerment, while
certain action areas are key, namely the
development of action competence, a
supportive school environment, links with the
community, the development of the
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curriculum and of teacher education, and the
measurement of success.
Health-promoting schools clearly
contribute significantly to the social and
economic development of society at large.
The approach must not be prescriptive; while
all schools need to act on a set of the core
values and principles noted above, the work of
each must reflect local cultural, organisational
and political considerations. Schools should
be viewed as a resource for the wider
community; for example, their facilities
should be available for use outside normal
school hours. Schools should act as a catalyst
in bringing together a wide range of
organisations in a co-ordinated approach to
community health.
The success of ENHPS across Europe
warrants further implementation, and there is
a continuing need for further development to
be evidence based. The conference, therefore,
called on the governments of all countries in
the European region to create the conditions
for the adoption of the concept of the health-
promoting school. The resolution asserted
that every child should now have the right to
benefit form the health-promoting school
initiative. It invited the European Union, the
Council of Europe and the WHO Regional
Office for Europe to continue their support
for the network.
Some further landmark events for the
ENHPS
The strategic focus of the network has been to
develop a strong and sustainable network. To
assist in this process, a series of landmark
events have taken place within the overall
ENHPS development plan. As a brief
introduction to these events, a selection have
been chosen and are outlined below.
The EVA 1 and EVA 2 evaluations of the
ENHPS
Both evaluations, funded by the European
Commission and supervised by the Technical
Secretariat, have provided vital data about
the implementation and eventual outcomes of
the network. The evaluations have been fed
into the workplans of the Technical
Secretariat.
 The European Network of Health Promoting Schools
Vivian Barnekow Rasmussen and David Rivett
Health education and democracy
Denmark 1994
This meeting was a defining point in the
evolution of the ENHPS. The meeting
focused on the participatory and holistic
nature of health-promoting schools and the
need for open and democratic processes to be
in place for teachers, pupils and parents to
learn and act together in the pursuit of health.
Action plans were made by countries and
some lasting collaborations between country
networks and individual schools were created.
Setubal Summer School, Portugal 1995
This meeting involved ENHPS national
co-ordinators, teachers and representatives
from school health teams, in working together
to gain deeper understandings of the health
promoting school processes. Teams from
countries worked to create closer
collaborations and common understandings.
ENHPS evaluation workshop, Thun 1998
This was the first meeting where the focus
was primarily on health-promoting school
evaluation methodology. Experienced
researchers from all participating countries
attended the workshop. The subject proved to
be both complex and essential for the success
of the initiative A report on the workshop will
shortly be available from the WHO Regional
Office for Europe.
Other events
Other events that have helped shape the work
and direction of the network have included
business meetings of national
co-ordinators, developmental meetings such
as the annual meeting of the national
co-ordinators from eastern and central
Europe, held in Budapest, national
conferences organised by countries, and
training programmes for teacher trainers
organised by the Technical Secretariat.
What has been learned
From the seven years of experience gathered
from the network, a vast amount has been
learned about introducing, establishing and
sustaining health-promoting schools at
international, national and local level. As the
network moves into the crucial phase of
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enlargement and dissemination, learning is
being integrated into the planning of the next
developmental stages. Many major learning
points from the initiative have been gathered,
which include the following.
It works
The EVA2 research, carried out in the 15 EU
member countries has provided compelling
evidence that the ENHPS does work at
international, national and school level. Data
from the research indicates that the concept
of the health-promoting school is recognised
as being a most effective way of planning,
implementing and sustaining health
education in the curriculum and keeping
health on the agenda. The EVA2 report was
published in autumn, 1999, and is available
from the WHO Regional Office for Europe. It
is planned to extend the remit of the EVA
project to eastern and central as well as
western Europe.
Collaboration
This is one of the hallmarks of the ENHPS.
Successful collaborations have been secured
and maintained at all levels of activity and
these have been recognised as a main plank
for development. More work, however, needs
to be done to integrate the ENHPS with
education processes and policy making.
Time
The ENHPS has now been operational for
seven years. Some countries have been part of
the network for this length of time.
Implementation and eventual sustainability of
the programme is a long process and differs
between country networks (Parsons et al.,
1997). Supporters and stake-holders need to
be aware of the time it takes to introduce and
sustain change.
Evaluation and effectiveness
Much evidence is available concerning the
need for comprehensive approaches to health
promotion. Effectiveness can be seen in many
forms and concerns policy developments at
international and national level and
developments of the whole school
environment, as well as understandings,
knowledge and behaviour of pupils. The
ENHPS has been able to show processes of
change at all these levels. Several tools and
 The European Network of Health Promoting Schools
Vivian Barnekow Rasmussen and David Rivett
services have been developed by the
Technical Secretariat to increase the
knowledge and understanding about
comprehensive evaluation. These have
included guidance on indicators for the
health-promoting school, an appraisal service
for countries to position the health-promoting
school approach more strategically and the
EVA2 country assessment tool. Additionally,
the Technical Secretariat acts as the
co-ordinating centre for the Health Behaviour
of School-Aged Children Survey (HBSC), a
cross-national study of pupils which now
involves more than 20 European countries.
The study is unique in many ways as an
example of international collaboration. It has
set a standard in research methodology,
involving pan-European gathering of
information; and a comparison of data, while
serving as a practical tool for education and
health policy making. A major effort will be
made to enrol more countries in the survey
over the coming years.
Dissemination and implementation
Several countries are now at a stage where the
pilot phase is moving into a dissemination
phase. This is a critical point in time for the
initiative and before embarking on strategic
development, a long-term programme of
development and implementation needs to be
undertaken.
Democracy
Equity and democracy are important
elements of the health-promoting school. The
role of the ENHPS in the democratisation
and transformation process in eastern and
central Europe has been remarked on is some
national development reports. In western
European countries there has been a
considerable rise in the number of students
being actively involved in the process of
developing the health-promoting school
concept, and the introduction of more
democratic processes is seen more often in
mainstream education policy in several
countries.
What of the future?
The ENHPS has and will continue to change.
As the development plan unfolds and is
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implemented, new tools and services are
developed and greater understandings of the
processes of health promoting schools
gathered. This has meant that, for the
Technical Secretariat new challenges are
being presented. Gathering, collating and
disseminating the learning will continue to be
a major task, for positioning evidence for
decision makers to use in the most effective
ways is a time-consuming process. In
addition, although 40 countries are currently
participating in the initiative, many others are
still eligible. Over the coming years, work will
be concentrated on expanding the
programme, where it is requested, to include
these other countries. At the same time, some
countries have now moved on from
supporting pilot networks of schools and are
developing work in further directions, some
through the creation of national strategies and
policy for health-promoting schools.
The ENHPS has achieved considerable
success in establishing the notion of a
comprehensive design to health in schools
through a health promotion approach. The
network has provided a platform for the
development of an international consensus on
health-promoting schools in Europe. As the
network has become more widely recognised,
greater attention is being focused on its
activities and goals. This is a powerful
development for the ENHPS which never set
out to be made up of a number of small
networks of schools. The need to spread and
expand the knowledge gained is essential for
the process to be sustained. This is the goal
for the ENHPS in the future.
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