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Knowledge Matters July-Sept, 2011
Canada's monthly school health report from the Canadian Association for School Health___________________________________________________________________________________________________
Volume 6 Issue 1 (July-September, 2011)
Volume 6 Issue 1 (July-September, 2011)
Featuring: Walking the Talk about New Approaches to School Health Promotion: A Review of the CCSA Standards for School-based Youth Substance Abuse Prevention:
As we move towards the eighth Canadian school health conference being held in Montreal on November 28-29, 2011, we continue our discussion of ecological and systems-based approaches to school health promotion that we had in the Apr-0June edition of this newsletter. This theme is one of the major ones being addressed in the conference and we use that lens to analyze the Standards for School-based Youth Substance Abuse Prevention recently published by the Canadian Centre for Substance Abuse.
We urge you to register for that exciting Canadian and international conference, which is being organized by CASH and three other partners; the Institut nationale de santé publique du Québec (INSPQ), the International Union for Health Promotion and Education (IUHPE) and the International School Health Network (ISHN). Over 500 people from around the world have already registered at the event.
CASH and ISHN members will benefit from a reduced registration fee for the Montreal conference. As ISHN launches it membership drive worldwide, it will be partnering with CASH and similar SH associations in other countries. To save $60.00 and also benefit from CASH and ISHN memberships, go to this web page, join ISHN, designate CASH as the partner and you will receive a code to use in registering for the Montreal conference. Go to the ISHN web site for more information; http://www.internationalschoolhealth.org/
Two pre-conference webinars have already been held to discuss the themes of the conference and more are planned. Go to the ISHN Webinar archive to access the digital recordings.
Changed Frequency of this Report, Call for Papers for this magazine Knowledge Matters,
Our 2500+ readers will note that we are continuing our move to a quarterly format for the publication of this report. We have struggled to produce a monthly version without the funding that we we used to receive from the Canadian Council on Learning. People who are interested in receiving the news on a monthly basis can still do so by “watching” the archives page in our web site, www.canadianschoolhealth.ca. When you are watching a selected page, the web site automatically sends you an email alert when that page is changed, which we will do each month. (You will need to be a member of that wiki-based web site (no cost, no spam) and you will need to adjust the controls in your profile once you have signed into the site so that you are watching that page.) We send out an email to everyone when we post the issues of Knowledge Matters in the web site, but the quarterly review of Canadian news, research and reports will now be more retrospective. If you are a real newshound and like instant gratification, you can follow us on Twitter at: http://www.twitter.com/shinsider_canad. We post Canadian items in that account several times a week. We are also posting international news, research and resource items on the welcome pages for some of our Communities of Practice. Go to these pages for the latest on these selected topics: sexual health, mental health and substance abuse prevention.
Our readers may have also noticed that we are now calling for papers to be included in this newsletter. We hope to move gradually to more of a magazine format. In 2011, CASH will be opening up this feature article space in the monthly report to others who wish to communicate with the over 2500 professionals and organizations who are on this email list. We will be looking for articles of about 1200-1500 words. We are hoping to receive submissions that include; fact-based commentaries on different issues in or aspects of school health, safety, social development, summaries of what we know and need to know about those issues and aspects or case studies or practice-based stories in local agencies and communities. Send your submissions to firstname.lastname@example.org
Canadian School Health Knowledge Network News
| Webinars/Web Meetings on Sexual Health Promotion |
Last spring, the Community of Practice on School Sexual Health promotion hosted three webinars, (Theseweb meetings will continue this fall, featuring panel discussions among experts from Canada and other countries as they answer participants questions and engage everyone in discussions). For more information and to register for these free web activities, go to: http://www.canadianschoolhealth.ca/page/Webinars+and+Web+Meetings
Five Webinars/Web Meetings on Implementation Issues in School Mental Health
A similar series of panel-based web meetings will be held on implementation and capacity issues in school-based and school-linked mental health promotion. Inter-ministry cooperation and leadership, inter-agency coordination, capacities & capacity-building, Evidence-based Implementation Models and Maintaining Fidelity to Evidence-based Programs or Approaches in the face of Complexity and Other Challenges. This series will start in June. Watch for the dates and times at: http://www.canadianschoolhealth.ca/page/Webinars+and+Web+Meetings
Four Year Knowledge Exchange Program in Substance Abuse Prevention
CASH is pleased to be working with the Council on Drug Abuse and the International School Health Network in providing knowledge development and exchange associated with a national peer-based program being developed and expanded in schools in three jurisdictions. The first CoP meeting and webinar for this CoP will be held on November 15, 2011 at noon (ET). This project has already hosted a recorded web meeting discussion on adapting substance abuse prevention programs to serve aboriginal students and schools. Go to the webinar archive to access the recording.
Thanks in advance to our CoP Chairs
Once again, CASH is grateful for the time devoted by the Chairs of our Communities of Practice. Here is a list of some great people; Eileen Antone (Aboriginal School Health), Judy Hills (Mental Health), Lesley Whyte (Substance Abuse), Mary McKenna (Nutrition), Delphine Melchert & Dwayne Provo (Disadvantaged Schools) and Roselle Paulsen (Sexual Health).
| Sign Up & Sign In: We are continuing to transfer the email contacts lists over to our professional networking web site at www.canadianschoolhealth.ca Agencies, organizations and individuals will be able to control the email they receive from this wiki-based web site through their own profiles. (This occurs by "watching" or "unwatching" selected pages). |
CASH-ISHN Membership Drive
The International School Health Network is partnering with CASH and similar organizations in the US, Australia and the UK to offer membership services that include:
- access to the extensive ISHN research/news/resources clipping service monitoring over 150 journals, over 75 media outlets and over 75 social media sources to bring a constant stream of brief info items with web links.Organizational memberships provide access to SH events for up to 15 employees. Provincial and territorial memberships are also available.
CASH: The Next Generation
As many will already know, CASH Executive Director Doug McCall is planning to semi-retire this fall and has been working with several chairs of the Communities of Practice so that they can continue their work using a variety of web tools. If you are interested in being involved in the evolution of CASH in the future, contact Doug at Dmccall@cash-aces.ca or 250.483.6988
Highlights of Canadian Research & News Stories from July-September 2011
With our change to a quarterly format for this newsletter, we will be highlighting selected events over the past three months. Go to the archive of monthly postings for all of the items.
| Highlights From July 2011 || Highlights from August 2011 || Highlights from September 2011 |
Feature Article: Walking the Talk about New Understandings in School Health Promotion: A Review of the CCSA Standards for School-based Youth Substance Abuse Prevention: Version 2.0 By Doug McCall, Canadian Association for School health
This article discusses the recent revised version of a guidance document published by the para-governmental organization, the Canadian Centre of Substance Abuse (CCSA), on school-based substance abuse prevention (SAP). This discussion focuses on the Version 2.0 of the document, which was revised quickly in response to several commentaries after the first version in the spring of 2009.
The intent of this discussion is to illustrate how new and emerging understandings and approaches to school-based and school-linked health promotion can easily be misunderstood or misapplied despite an abundance of financial resources. We also examine the knowledge exchange strategy and activities undertaken as part of this ten million dollar project managed by CCSA. Further, we briefly analyze the inventory of web-based resources and collection/analysis of local “initiatives” that were part of the original plan for the project. We also briefly examined the two other standards documents (on families and communities that were also published by CCSA). This five year project presents a significant learning opportunity for Canadian practitioners, researchers and officials and is presented as such in this commentary.
The CCSA standards document reflects others that have been adopted over the years as advocates, decision-makers and researchers working on various health issues have learned that multi-intervention approaches and programs on their respective issues is more effective and indeed necessary. Our Association is proud to have worked with many organizations, departments and ministries, including CCSA, to encourage that basic understanding of CSH. (We were not involved in the development of this document except for submitting an unsolicited commentary on Version 1.0 which led to a broader consultation and subsequent revisions published in Version 2.0. CASH was involved in the overall project advisory committee which did not discuss the content of the standards document except on two brief occasions.)
But it is time to go beyond that simple traditional understanding of SH promotion and truly address the issues identified in our new understanding and approaches. These include attention to issues of capacity, adapting to different local contexts, learning how to use evidence/experience-based implementation models as well as evidence-based programs, addressing educator concerns and pre-occupations directly and more. As well, this analysis will show that the CCSA document and project failed to walk the talk in respect to new understandings about school health promotion and effective knowledge exchange. With a budget of ten million and a five year mandate, this project should have delivered a far better product and a far more extensive diffusion process.
The school guidance document is one of three such “standards” documents published by CCSA as part of a project that also included the operation of a national youth substance abuse advisory committee and a web-based television project. Work on version 2.0 of the document was undertaken soon after its initial release in May 2009 and was subsequently concluded with a revised version about a year later.
The Canadian Association for School Health gathered feedback from the members of its Community of Practice (CoP) in school SAP programs and was among several organizations and individuals who submitted far-reaching comments and suggestions to the CCSA School Standards Task Force at that time. That CoP feedback as well as our two decades of work in school health promotion provides the basis for this analysis. In particular, we were very interested in examining whether the revised CCSA school standards reflect new understandings and emerging approaches to prevention and promotion in schools. An academic version of this analysis is being submitted to appropriate Canadian and addictions journals.
The Basis of New Understandings about School Health Promotion: An Ecological and Systems-based Approach
In recent years, several prominent researchers in school health promotion have realized that the traditional strategies used in advocating for comprehensive approaches, coordinated programs and whole school strategies to promote health or prevent problems have a fundamental flaw. While the research evidence underlying many individual interventions as well as the value of coordinated multiple intervention approaches is solid, the capacity of health, educational and other systems to implement, coordinate and sustain these programs is not sufficient. Further, the linear logic underlying most prevention efforts fails to take into account the complexities of school-family-neighbourhood interactions as well as the differing needs of specific communities such as disadvantaged communities, indigenous communities, faith-based schools, rural schools and affluent schools.
As a result, health advocates constantly compete among each other to persuade educators and others of the importance of their disease, seek, obtain and then lose their short term funding as public, political and professional attention waxes and wanes. The front lines of open, adaptive, loosely-coupled, professional bureaucracies of education, public health and other systems are quick to adopt small-scale innovations such as new instructional programs or new procedures but are resistant to long-term shifts in their core priorities and equally quick to respond to the next new demand being placed on them.
Researchers in Canada, like many others around the world, (See this summary) have articulated this new "ecological" understanding that health and social behaviours and status are the result of multiple, complex interactions between the traits of the individual, the family and the neighbourhood. In Canada, the ecological model has been paired with a “systems” approach that tries to understand and influence multi-level systems such as education, public health, social services and addictions to work more effectively in and with schools. This action focus on systems working within the inter-twined ecologies of schools, families and neighbourhoods is to take the new perspective from an ecological understanding to action based on ecological strategies and models.
The CCSA document provides the first part of this ecological discussion by presenting the risk and protective factors associated with problem substance use in an ecological framework in the Appendix. The individual school, family and community factors are described quite well in presenting this understanding of how the various factors interact with each other. The problem is that the CCSA document does not then move towards re-orienting our logic models, program and policy development and selection and organizing our interventions in an ecological, rather than traditional, linear, program-focused manner.
The lessons learned from this new understanding are now being published by many researchers working on several issues as well as on overall health, safety, equity and social development. The implications of this new, basically different approach are quite profound and go beyond the traditional call multiple intervention approaches and programs which we have all promoted for the past twenty years. Here are the some of the new strategies, logic models, and ways of identifying issues and programs that are emerging from this ecological and systems-based approach.
- Promote not only multiple interventions but also promote actions at multiple levels in multiple systems
- Use different program logic models than the traditional, linear, medical model, where a priority issue is selected based on medical grounds, a short term (2-3 years)intervention is selected and tested for dose, duration and intensity in controlled conditions and then the experimental results are applied in controlled conditions elsewhere with expectations of life long impacts. Instead we can:
- Start with the health/social needs of a population and local context, then help them identify priority issues and clusters of issues, then select synergistic combinations of programs drawn from several models of school-based and school-linked work (Rather than selecting an issue at a provincial/national level, setting general goals, then adapting it to local circumstances
- Start from a capacity/community development model and seek improvements whenever and wherever possible based on local strengths, needs and opportunities (Rather than seeking changes on one issue on all communities)
- Choose from among behavioural, community and organizational development theories and models and then build that framework over time. (Rather than inventing a new framework and infrastructure each time a new issue arises)
- Ecological systems are open and adaptable to emerging changes and new demands in their environments but system stasis, boundaries, changes in the environment and system-environment interactions will ultimately determine the long-term response to any specific demand/innovation.
- Open, loosely-coupled systems are adaptive to small scale changes (innovations) but often resist large scale change (reforms). Consequently, school systems will adopt new specific health issues/programs and drop older health programs very quickly. They will also resist demands for a shift away from their primary literacy, custody, vocational and accreditation roles to focus on life-long healthy lifestyles
- Loosely coupled systems are more dependent on professional and social consensus for their decision-making and will therefore be influenced more effectively by addressing adopter concerns directly, identifying policy levers and incentives that system managers can use and acquiring a deep understanding of the roles and preoccupations of front line staff, middle managers and senior staff as well as organizational readiness for change.
- Education, public health, welfare, police services, social service, addictions and other government systems are operated by "professional bureaucracies" that are multi-level, are dependent on structures, job descriptions, routines and procedures, have formal and informal communications channels and internal social networks, make decisions based on non-rational grounds and are led by individuals with perceived, specialized forms of knowledge, have their own professional norms, sociology, work life/career patterns and cultures.
- Systems management, normally complex in large systems, becomes even more so when we realize that school human development programs must work across several systems which often have competing priorities and scarce resources and at multiple levels within those systems. Consequently, we need to clearly define what we need in regard to the degree, forms and nature of cooperation needed at the school/professional, school board/agency and inter-ministry levels.
- A System is more than the Front Line Workers
This clarification exposes the basic misunderstanding about ecological and system-based approaches, despite the references to such in the introduction to the document. Ecological mean multi-level action, not just hoping that front line educators will take up the challenge despite all of the other demands of their jobs. The document is void of suggestions for education ministries, school boards or other agencies. If we are using a systems approach, then discuss the entire system, not just the front line.
Further, the document notes that there isn’t yet a defined “prevention worker” or “professional” designation or training path for individuals whose work involves the prevention of substance abuse. We also know that very few, if any schools, have substance abuse prevention committees and that if there are school health committees in schools, they are likely supported by nurses and are more than likely focused on nutrition, physical activity and similar issues.
The non-existing audience selected for the CCSA standards reflects its continuing use of an out-dated, front-end loaded model (WHO, 1997) of school health promotion, a problem that was cited in earlier criticisms of the first published version. The revised version continues to refer to the WHO model but also refers to a similar, simple CSH model developed by provincial/territorial government officials and published by the Joint Consortium for School Health. The JCSH model also uses a standard and basic description of four types of programs (social and physical environment, instruction, services and policy) but also avoids any discussion of ministry or school board/addictions agency or health authority roles.
A key element of the new ecological and systems-based approach is that it is multi-level, multi-system in nature. Education, health and other ministries as well as other agencies must meet certain standards of policy, coordination and program support if local schools and professionals are to be successful. How can we ask a committee of educators and other front-line professionals to plan and implement ongoing and sustainable prevention initiatives if these kinds of system changes and structures are not in place?
- Social service agencies, addiction treatment centres need to have services in place so that educators can refer troubled students to help from mandated professionals
- Police officers and youth courts need to have procedures and supports available to divert students from further confrontations with the law
- Education ministries need to design their curricula so that there is adequate teaching time and materials available for SAP specific learning as well as overall health/development
- School boards need to allocate funds for professional development to health teacher skill development and education faculties/ministries and teacher colleges need to provide better preparation in pre-service programs
- Social service agencies need to fund local community-based organizations to provide after- school programs for youth and those organizations need to establish protocols with local school boards to working with schools.
- Linear Logic Models are less than useful in complex, ecological, multi-level systems
Yet, Version 2.0 of the CCSA document spends increased time explaining linear logic models in its section on evaluation. The controlled process suggested in both the output-oriented process evaluation standard and the outcome-focused outcome evaluation fits well with on-paper thinking, evaluation of specific projects and programs and with the random controlled trials made possible through research grants but is far beyond the reality of local schools and far beyond the time available to local school teams.
The CCSA document vaguely suggests a process whereby local school teams gradually adopt better practices over time and no one can argue against that basic idea. But the document needs to add detail and precision as well as suggest evaluation criteria that are more in tune with an ecological approach. Most researchers working from the new approach to SH promotion suggest a monitoring and reporting system that tracks the changes to a variety of inputs, processes and outputs at different levels in the relevant systems. In other words, we should be looking for gradual, multiple and coordinated improvements in the overall ecology and not be solely focused on specific behavioural outcomes until we can say that the “system” has truly changed.
- Standards or Aspirational Goals?
But, of course, if CCSA were to develop standards as defined conventionally above, they would have needed to describe the what is normal or average level of activity in the various practices suggested in the document. This would have to be established either through a national survey or through a well-documented and explicit research strategy.
In fact, the CCSA did not conduct any such survey to determine the current state of practice and instead chose to consult with national and provincial intermediaries about guidelines, standards and other goals. If CCSA had conducted such a survey, they would have been a reasonable basis for setting realistic standards in the true sense. The results of the survey, when used with a similar survey at the end of the project, would also have been an excellent way to evaluate the impact of the five year CCSA project.
Another way to determine if a “standard” is reasonable is to have an extensive research program that can delve into other studies and then track down their related materials and reports to determine if they could be applied to Canadian schools. The Best Practices portal of the Public Health Agency of Canada uses this methodology in selecting programs to include in the portal.
Unfortunately, there is no description of the search methodology used to gather evidence for the project contained in the CCSA document. Normally, the search words, databases, publishing dates and other steps are described. Three Canadian documents (two of which were older than eight years) and 13 international reviews (all but one was older than five years) were cited as the primary sources. Our association was involved in the writing of two of those documents, both of which used a rapid review methodology and both of which were limited in their scope and application. With a budget of ten million over five years, it is reasonable to expect something better and different than the previous documents.
A cursory look into the research in preparing this commentary, using only the databases maintained by Health Evidence Canada and the International School Health Network alone, found 94 systematic reviews and major articles that were not listed either in the major bibliographic or specific references in the CCSA document. Normally, there are always differences between various reviews but the gap is far too large in this case to ensure confidence in the CCSA search strategy, particularly since it is not described in their document.
Returning to the discussion about the use of the term “standards”, if the criteria and better practices suggested in the CCSA document are indeed aspirational goals as developed by a small group of experts and advocates working alone and based solely on the limited number of research and other materials that they are currently using in their work, then the “standards” should be described as goals. Having lofty goals is a good thing, but it can be a discouraging or cynical exercise if we then ask schools to measure their performance against such aspirations instead of having a reasonable set of achievable objectives.
- More than Just Talk about Capacity
First, it should be noted that there are some established frameworks for describing system and school capacities (World Health Organization, 2003) and these have been adapted here in Canada by a network of researchers (School Health Research Network, 2005); over 25 national organizations in their CSH Consensus statement (Canadian Association for School Health et al, 2007) and on the web site of the Joint Consortium for School Health, ND) but the CCSA document does not use these well-established Canadian models. An amalgam of these Canadian definitions of operational capacity is as follows:
- comprehensive and coordinated ministry, agency/school board and school/professional protocols/mandates on school health, health issues and the elements of school health promotion that are actively supported by senior managers should include financing, administration and organization. These explicit, comprehensive policy and managerial supports for inter-ministry, interagency and inter-disciplinary coordination and cooperation should include procedures in policy-making, program planning, and budget preparation to align responses to health and social issues undertaken through and with the school systems. As well, an overarching policy should favour inter-sectorial approaches and it should be reflected in guidance and directives to school, public health, police, social service and other local authorities and agencies
- formal and informal mechanisms for inter-ministry, inter-agency and inter-professional coordination and cooperation; these mechanisms help to manage the implementation process, avoid confusion, and capitalize on synergistic action. Mechanisms may include joint committees, job descriptions, written policy statements, joint in-service programs, joint planning, shared budget allocations, joint vision development and consensus building.
- assigned staffing and infrastructure to support inter-ministry, inter-agency and interdisciplinary coordination and cooperation at all levels; Assigned staffing and infrastructure, such as provincial/territorial and district school health coordinators, help to facilitate and support interdisciplinary coordination and cooperation in school health promotion. These staff assignments should include time for actively supporting voluntary cooperation and alignment of activities, programs, policies and practices. They should be based on explicit intergovernmental, inter-ministry, inter-agency and inter-disciplinary agreements and should ensure that the voices of youth, parents, professionals and volunteers are heard in the decision-making about policies and programs.
- ongoing workforce development of health, social service, police, education and other professionals through professional preparation programs and staff development includes explicit and sustained programs and processes to develop ministry and local agency workforces, through studies of current professional practices, guidance and support for the development of university and college pre-service preparation programs, and development of guidelines, models and materials for sustained staff development programs.
- Ongoing and active knowledge transfer and exchange within and across sectors includes mechanisms and processes to sharing evidence as well as local solutions and ideas for implementation, funding and evaluation with decision-makers and practitioners to describe lessons learned and promote promising practices. This would include evidence-based knowledge summaries published by a variety of sources, guidelines for policy, programs and practice from provincial, territorial and professional sources and tools and models that enable decision-makers and practitioners to reflect on their situation and their practice and to locate materials and models that can be adapted to their circumstance.
- Regular monitoring and reporting on system, organizational (agency and school board), school and professional performance and capacities uses carefully selected indicators based on reliable data sources to produce regular reports on system/organizational performance over time as a tool to focus system reform and improvement. Effective M&R systems record changes over time in the local context, inputs, processes (programs, policies, practices) and outputs (short term health/social status, behaviours, knowledge, skills, attitudes). Specific surveys and reports on aspects of health, selected sub-populations or program evaluations can be done within the context of this overall reporting system but are not a substitute for such a system. M&R systems are similar but different than program evaluation, self-assessments, one-time or ongoing surveys or cohort studies of children. M&R systems report regularly and publicly on the overall characteristics, results and capacity of the school and other systems, agencies and professionals as well as the healthy development and health related learning of children and youth.
- Early identification and strategic management of emerging issues and joint priorities; health and education systems need to have clearly identified priority issues. But they also need to identify emerging issues and address those issues; otherwise they will go outside the established process and push their way into the open, loosely coupled system in another way.
- An explicit sustainability plan that includes long-term planning and sustained fundingensure the continuance of programs that demonstrate effectiveness, based on regular evaluations that shed light on program process, context and outcomes. Financial resources are needed for staff, personnel training, infrastructure changes, coordination, intersect oral participation and dissemination to support continued implementation and school health promotion action and evaluation plans.
In the next paragraph, CCSA states that “there are many ways of viewing capacity but it can be seen as the potential of a school or a team to take action”. The document goes on to say that the school team “critically reflect on school, team and partner capacities on an ongoing basis” and make adjustments if necessary.
In these few words, the CCSA document up-ends the whole concept of capacity and capacity building to once again place the burden on the school and front-line staff rather than looking at the various, multi-level systems that need to be involved. As well, the glaring omission of the Ministry of Health or provincial, local addiction or police agencies from the list of partners who might “perceive” that they share some responsibility for school substance abuse prevention places the entire discussion of capacity in a bad light.
The discussion of capacity in Standard Number 5 in the CCSA document is equally revealing. The obvious rationale for this standard is stated by noting that “it will be difficult to sustain initiatives whose goals and activities exceed the available resources” and then reiterating that it is up to the school-based team to assess the different types of leadership, collaborative, technical, cultural and financial capacities available to them and then manage them effectively. A brief sub-section is added to this standard that examines how school staff (i.e. teachers) can “introduce innovations to overcome some of the barriers.
Standard 8 of the CCSA document suggests that schools strengthen their links with parents and communities by engaging parents and working with community-based organizations to offer youth programs, after school programs, truancy prevention services, youth employment programs, better access to health care services and coordinated case management systems. What happens if those organizations are not funded, mandated or willing to work with schools?
Standard 9 of the CCSA document suggests ongoing professional development for teachers, both to improve their teaching as well as their enforcement of school SAP policies. This is true but it is not possible if the school board, education ministry or another part of government or agency provides the funding for this ongoing teacher development.
Standard 10 of the CCSA document suggests three keys to sustainability; active and ongoing support from the school principal, linking substance abuse prevention to the core educational mandate of the school and having a good implementation plan. While these three things are important, these items are not usually included in the evidenced-based definitions of capacity described above.
The workbook section of the CCSA document also refers to capacity, with a similar glossing over of its meaning and substance. In the “20 Minute Reflection” version of the Handbook, CCSA suggests that the local school teams ask if they are “strengthening the links with parents and other partners” and if they do professional development on an ongoing basis. In the In-Depth Review section under Standard 5 (Planning & Capacity), the CCSA document suggests that school teams ask themselves if they have:
- learned about and applied a comprehensive school health framework to their prevention efforts
- examined whether their prevention activities were effective
- assessed their readiness to begin a new innovation
- learned what community agencies are available to support their school’s efforts
In the In-Depth Review section under Standard 8, the CCSA document suggests that school staff look for evidence that they have:
- incorporated their efforts within a broader school health framework,
- ensured representation of the different community partners on their school team
- included a family component to their efforts
- linked their school efforts with community initiatives
In the In-Depth Review section relating to Standard 9 (Professional Development), the CCSA document asks school staffs to determine if they have:
- prepared teachers and health promotion/prevention staff in student centered and interactive instruction
- coached teachers and other staff in addressing sensitive issues
- prepared teachers and staff in the use of participatory methods and in engaging youth effectively
- addressed staff health and wellness
In the In-Depth Review section relating to Standard 10 (Sustainability), the CCSA document asks school staff to determine if they have:
- created an evidence-based argument that substance abuse prevention should be part of the core school mandate
- educated staff and parents about substance abuse issues
- sought long-term funding for their initiative
- embedded prevention and health promotion into school statements of core values or core mission
In other words, the onus on developing capacity for prevention is always placed on the school staff rather than the entire school system and other systems, agencies and professionals.
In our examination of this CCSA standard on capacity, we looked for some evidence that the general idea of capacity had actually been applied in a meaningful way, such that there can be a determination whether that a “standard” being met by the school was a normal or reasonable requirement in terms of quality, quantity, level or grade and/or that the ministries, local school board or health authorities or professional capacity was being added or provided.
The various parts of the CCSA document noted above are all good descriptions of a desirable or aspirational future and legitimate goals, but they are hardly any definition or description of the capacity required so that the school staff can determine if they have the capacity to achieve their plans. To use an example, ensuring that community agency representatives are sitting on a school team advising teachers can do in their work is one thing. Negotiating an agreement with those community agencies that they will deliver personnel or services to specified levels in the school is quite a different matter.
Using the eight point capacity model discussed above, CCSA could have suggested that school teams ask these kinds of measurable and specific questions about their capacity:
- Do the health ministry and education ministry have a coordinated set policies and guidelines for school-based substance abuse prevention?
- Have their school board, local health authority and addictions agency adopted or adapted those policies and assigned funds and personnel accordingly?
- Are police officers mandated to work with schools and assigned to work with schools as school resource officers?
- Are the addictions workers in local clinics mandated to work with schools and does the school have an agreement with those professionals about how they will serve their school?
- Is there a person (police officer, public health nurse, addictions worker, vice-principal, etc.) that has been assigned to coordinate the school’s efforts in prevention? Has time been allocated in their job assignment or job description?
- Do the school board, health authority, police department and addictions agency have a written agreement covering responses to incidents, support when working with parents, help for troubled students etc.? Has this inter-agency policy/procedure been discussed with the local school psychologists, social workers, nurses etc.?
- Is there instructional adequate time available to cover the suggested learning objectives in the CCSA standards?
- Has the school incorporated various monitoring and reporting items related to substance abuse into its annual school planning such as reporting on the number of incidents, referrals to various child and family support services, number and types of school activities, meeting s with individual parents and with groups of parents?
Baseline Capacity (minimum staffing, curriculum time minimum service levels)
Another part of the consideration of capacity and capacity-building is defining the minimum resources required to achieve the minimum objectives that have been described and documented through research. (Most descriptions of the various levels and ingredients required test only one level of intervention(s) with no interventions used as the control group. Or, the description is based on assertions made or collated by advocates for that type of intervention and therefore are more likely describing the optimal level of intervention.)
With a budget of ten million dollars it might have been possible for CCSA to answer some baseline questions about minimal system and organizational capacity such as minimum learning outcomes for students, the teaching time required to reach those outcomes, minimum staffing ratios for school resource officers, school social workers, school psychologists but this was not attempted, nor discussed.
- Different Local Neighbourhood Contexts as well as Different Types of Students
Further, the CCSA document does not mention, let alone address one of the major implications of an ecological understanding and approach to school health promotion. The local neighbourhood context matters very much in determining the needs of the school as well as their capacity to respond to their needs. The issues we choose to address, the nature and clustering of those issues with others, the types of programs and services that are feasible and acceptable to the community, the synergies of combining programs in different ways can all be derived and developed differently for different types of schools and neighbourhoods. Educational systems and educators have long recognized this and correspondingly discussed the delivery of educational programs in these kinds of schools/neighbourhoods:
· Rural, isolated schools
· Urban schools in disadvantaged communities
· Religious schools
· Band schools or schools serving large proportions of aboriginal students
· Affluent and private schools
The CCSA is not alone in failing to differentiate program needs and possibilities in different types of schools in this education-driven way, but it is still yet another example of how the CCSA document does not walk the talk about ecological, systems-based approaches to program planning and delivery.
- Integrating within, not just with, education mandates, pre-occupations and constraints
The five core functions that schools play for society are noted below in their order of importance (with an emphasis or elaboration provided in italics)
- Schools provide safe custody for children during the school day (and will act quickly to eliminate any threats or disruptions to that safe environment)
- Schools ensure that all students leave schools with basic literacy, numeracy, scientific and technological knowledge and skills, a basic knowledge about history, geography, and obligatory exposure health, physical activity and the arts and selected other subjects with options to learn more in elective courses(with the emphasis clearly on literacy, numeracy, science and technology)
- Schools accredit students with a basic level of literacy skills for graduation and will select some students for higher levels of education at university, college or training (and will fail a gradually increasing number of students at each grade level as part of the selection process in order that they meet the standards imposed by government or higher education institutions)
- Schools provide basic training in work habits and provide some opportunities for students to learn about and explore various jobs and careers (with a bias towards careers requiring university preparation or jobs that encourage young people to seek employment/jobs provided by others rather than creating work for themselves).
- Schools socialize students into the dominant ideology, norms, practices and cultures of their society (and help to reproduce the next generation of leaders and followers of these traditions)
In particular, health advocates have ignored the implications of the school’s role in accrediting/failing students and in social control measures to protect the learning of all students.
The CCSA document suggests four basic interventions for schools to use in developing a substance prevention abuse “initiative”. They are:
- Cultivating a positive school climate for all
- Delivering developmentally appropriate classroom instruction at all levels
- Implementing "targeted activities' (ie support services provided by educators, not health or addictions services professionals) within a comprehensive continuum of services
- Preparing, implementing and maintaining school board and school policies
First, let’s examine the notion of improving the school climate for all in the school. Recent research on school climate is documenting how different students perceive and interact with the climates in their schools. Booren et al (2011), Wan et al (2011) and Connor et al (2011) are among the researchers who are now differentiating among different types of students and between teachers and students in regard to how they perceive the climate of their schools and how that perception affects (or not), their use of substances . Increasingly, we are learning that some students, usually those who are having trouble with their school work and with their families or peers, perceive the climate of their schools differently than other students. We now know that as early as grade one, we can predict social and emotional problems among students who experience problems at school. Trying to have all students “connect” better with their schools is not the panacea that many would have us believe.
When we look at the imperatives for schools imposed by the five functions of schooling, where safety/orderliness for all students, accreditation/sorting/selecting students and a bias towards academic achievements are paramount, we can question the effectiveness of expecting that efforts to improve the overall school climate for everyone will also meet the needs of students who are already being pushed out of the system. Instead, the CCSA document could have suggested multi-intervention programs such as the wide spread Effective Behaviour Support (EBS) program (Sadler & Sugai, 2009) or the Response to Intervention Model (McIntosh et al, 2011) , which identify, track and support troubled students. These evidence-based programs that focus on the adaptation of students at risk within the overall school climate and operations will be more effective than generalized attempts to increase student and staff morale in preventing substance abuse, albeit that such morale is a good thing.
Similarly, the suggestions related to developing and implementing a “developmentally appropriate classroom instruction at all levels” shows both an ignorance of how school systems operate as well as a lack of understanding of how crowded and controlled the core curriculum is for school systems (especially when understood in the light of the description of the core mandates of schools above).
The advice provided in regard to instruction is all well and good even if it is somewhat redundant to most health curricula already in place in Canada. However, if the target audience for the CCSA Standards are teams of local school professionals, it does not make sense to advise them on curriculum design issues. Teachers, schools and school boards make decisions about the selection, purchase or development of lesson pans and teaching/learning materials. They do not develop curricula, which are statements or prescriptions about required or recommended learning objectives that are often accompanied by recommended teaching/learning and student assessment strategies. It would have been more productive and appropriate for CCSA to set some specific standards or provided advice about selecting or adapting instructional programs to school level teams. Another strategy that might have been used is for the CCSA document to assess the various lesson plans and instructional programs available and then published that list for school-based educators.
Most provinces and territories review and revise their curricula at very infrequent intervals, and then it takes several years to develop, pilot and then gradually introduce the curricula. So providing curriculum design advice to teachers in schools is irrelevant. Further, given the constraints identified in the section of core mandates of schools, it is not likely that the amount of teaching time available for substance abuse topics in the health curricula will change very much at all. So, suggesting that a K-12 scope and sequence for the substance abuse component of the health curriculum to members of school-based teams, when it already has been done by the provinces or won’t be done in the near future by the provinces, does not make much sense in the reality of school systems today.
Similarly, the third type of intervention recommended by CCSA (educators implementing targeted in-school actions to support students at risk) is all well and good except that it begs the more important question about who will provide health, addictions services and supports to these students when they are outside of the school. The actions suggested by CCSA include teachers being alert to student problems, having peer helper programs in place, mandating the guidance counsellors to identify and support students experiencing personal difficulties, stipulating referral procedures for teachers, and so on are all good. But these actions by educators will be in vain if they are not backed up and supported by police officers willing to intervene and divert troubled youth away from the courts towards support, by family and youth counsellors who are available and mandated to intervene with educators, by social workers who respond quickly to teacher reports of neglected children and youth, by youth addiction centres who work closely with schools, then many of the in-school, educator actions will only be providing band aids for more serious problems driving the youth consumption of drugs, alcohol and tobacco.
The same mistake is made when CCSA recommends policy-based action but refers only to school boards and schools in that section. Education, health, law enforcement, social services and other ministries all establish policies and procedures that affect the delivery of school-based and school-linked programs and services. As per our discussion of systems capacity, these inter-ministry, inter-agency and inter-professional policies and professional mandates need to be coordinated as part of a whole of government approach. The schools are part of the fabric of their communities and cannot be singled out in such as artificial manner. To use our wetlands analogy, it is like asking and expecting the birds to stay and flourish in the marsh after developers have diverted the water flow and used massive amounts of pesticides.
- Addressing Adopter Concerns
Educators, as part of their professional norms, are focused equally on all students; their learning needs and potential to achieve their best are all equal. Therefore when one student disrupts the class, the tendency to exclude that student in order to to protect the rights of others is very strong. There is a reason why the term “orderly” often appears in the educational discussions about effective schools. Consequently, in regard to substance abuse, school staff will first want help from addictions services and police to manage troubled kids. The research on implementation calls this responding to adopter concerns in order to secure their involvement in the innovation.
Many educational jurisdictions have worked their way through immediate, reactive, poorly thought out responses to drug related disruptive students such as “zero tolerance” policies but the enlightened alternatives to school suspensions requires policies and programs from addictions services (treatment, rehab support, reintegration support etc.) as well as from police in regards to diversion and restorative justice programs. However, the CCSA standards document specifically excludes discussion of role of treatment clinics and addictions workers. As well, other procedures such as locker searches, responding to incidents, working with troubled families are all missing from this document. Thus, the immediate and priority concerns of the primary adopters are not being met. Further, the exclusion of these urgent concerns defies our new understanding about school health promotion and prevention that suggests that many agencies and professionals are required to be in schools delivering ongoing service in some designated ways.
- Teacher Work Lives: No time for Meetings, Less Willing to Collaborate
- are often isolated by the workplace structures
- often did not have an active career plan and are in an occupation that does not have a strong career trajectory to reward experience and skill
- teaching careers are “un-staged” and front-end loaded in terms of financial rewards
- becoming an administrator is not seen as a rewarding change
- often come across as conservative and even ambivalent in their attitudes,
- were often selected to teach in communities that held the same values as those that they grew up with
- found their chief motivation and inspiration in the daily satisfactions of reaching and changing kids
- work in an occupation that is governed by non-teachers rather than their peers, where entry requirements are kept loose because of periodic teacher shortages, where the work place does not promote inquiry
Roland Barth (2006) suggests that the interpersonal relationships among staff within a school are the most powerful influence of the culture of that school and its ultimate effectiveness. The relationships among staff members will affect their relationships with students and parents. He notes that there are a number of “non-discussables” that revolve around those adult relationships that affect the school. They include the leadership of the principal, issues of race, underperforming teachers, their personal visions of a good school and the relationships among the adults in the school.
Barth also describes how teachers are isolated workers, living in separate caves in their schools. This is often the nature of the workday for most teachers. Teachers tend not to share their craft knowledge with each other. He describes the written sign that is outside most teachers’ staff room – no students allowed. He then points out the unwritten rule of many staff room – no talking about teaching in the staff room. He also notes that teachers become very apprehensive if someone observes their teaching in the classroom.
Tuohy & Coghlan (1997) have developed a multi-level analysis using a systems approach. They suggest that staff participation in school life can be analyzed on four levels: the individual, the team, the inter-team cooperation and the school as a whole interacting with its environment. This type of in-depth analysis needs to be part of SH promotion and practice.
They present an intensive framework for each of these levels that is valid for school health promotion. They view schools as social systems, where there is an integral link between how policy is formulated and implemented, how work is managed and coordinated, how people work together and how the individual teacher finds career satisfaction is essential to the coordinated development of the school.
They go on to describe the working of the teams within the school. They note that, traditionally, teaching has been a private matter, between the teacher and the students. Indeed, this is one of the few areas where an individual teacher may feel in control. However, new demands on schools, including coordinated school health programs, often require a whole school approach as well as partnerships with the community. These new school approaches often include:
Management structures such as parent advisory councils, subject departments, staff committees, student councils, community liaison committees
Educational planning – including participation in board and ministry committees, master teacher programs, student teachers
Pedagogical planning – including teams to implements new curricula, select prevention programs, improve school outcomes.
Tuohy & Coghlan note that often teachers are not effective in such teams and committees. They cite Hargreave’s description of “contrived collegiality” where problems are often not addressed. This means that the silent minorities of teachers often simply return to their classrooms to await the demise of the innovation being proposed.
Further, all of these insights into teachers work lives are underlined when we consider how little time and respect is given to planning time for teachers. Professional days are always questioned by parents because it they interrupt the custodial (day care) service provided to them. Teaching time is maximized between school bus times, so it is rarely possible for teachers to meet informally because they are always teaching or preparing for the next class. The few professional days available to teachers are often taken up with workshops and meeting topics identified by the school board or others.
In short, teachers have little time for group planning, are less inclined than most professions to work together, and are usually not supported in doing so through release time from their teaching. Teachers who do take the lead on issues or projects are either promoted or they burn out from their double duty. And principals are rightly concerned with a multitude of non-health issues every day and cannot be expected to provide ongoing facilitation and team leadership on every issue.
Yet, teacher collaboration with colleagues and outsiders is the basis of the improvement process suggested by the CCSA document. The CCSA document does not identify the external professional (such as nurses, police officers, addictions workers) who can and should facilitate the process in schools but instead suggest that we leave this up to chance. This core capacity, the assignment of a coordinator, is required for every successful program. But who that person should or will be it is left unanswered by the CCSA document.
The CCSA Document Does Not Reflect What we Now Know
In conclusion, and as illustrated throughout this analysis, the CCSA School Standards fail to act upon the research and practice-based discussions about ecological and systems-based approaches to school-based and school-linked health promotion and prevention. The burden for systemic change is placed, inappropriately, on the front-line people (teachers) on only one system among the many that are responsible for school-based and school-linked prevention. The multi-level ecologies of schools are noted in a theoretical discussion in the document but not acted upon throughout its content. The need for system, agency, school and professional capacities is ignored, except for the traditional call for more professional development for teachers. The four types of educator-only interventions suggested in the document are problematic without the support from other systems, agencies and professions. The document has not used what we now know about teacher work lives and has not responded to their immediate concerns about troubled students.
The Other Activities in the CCSA Project are Also Frail
Time and space in this document does not permit an in-depth analysis of the other activities that were funded by the ten million dollars received by CCSA for this five year project. These include:
· Two other similar “standards” documents
· The facilitation of a National Advisory Group on Youth Substance Abuse Prevention (YSAP)
· The development of a database of prevention resources
· The collection and analysis of local “initiatives” that would also be collected into a database
· The development and production of a web-based television show for youth to watch after school.
We are not able to analyze the two other standards documents but we are able to comment briefly on the other activities.
Youth Substance Abuse Prevention Advisory Group
The National Advisory Group on Youth Substance Abuse Prevention (about 25 member organizations) met face to face twice yearly and held 3-4 conference calls early in the life of the project. The number and nature of the participants was good in the beginning of the project but fell off significantly throughout the project. Most of the meetings were taken up with presentations and progress reports from CCSA staff, so the YSAP did not serve as a national leadership group but rather as an advisor to CCSA activities. It also did not serve as a “community of practice” or even a knowledge exchange network for organizations concerned with youth and substance abuse. The YSAP was not directly involved nor informed about the detailed work on the three standards documents (which was done by groups of experts). A most telling feature of our meetings, even in the latter stages of the project, was that we had to have “ice-breaker” activities at all meetings so that the new participants at each meeting got to know each other.
If the purpose of the YSAP was ongoing knowledge exchange, it did not achieve that objective. Any successful KE process builds trust and relationships, shares leadership functions and is a forum shaped by its users. The YSAP may have served CCSA needs in serving as an advisory committee for its activities or interests but did little else.
Database of Prevention Resources
As of the writing of this analysis, CCSA had collected 116 school related resources in this database (located by searching for all school resources) of these resources, the following breakdown was done as part of this analysis:
· General fact sheets on substance abuse (14 resources)
· Statistics and other background on the prevalence and nature of youth substance abuse (17 resources)
· Documents or tools in general health promotion, prevention or youth development (30 resources)
· School-focused tools and documents (39 resources)
· Not applicable or place holder items (16 items)
As one can see from the breakdown, most of the resources identified in the CCSA database are actually not focused on school-based or school-linked health promotion or prevention. Only 39 items pertain directly to schools.
The CCSA collection of resources compares unfavourably with the online collection being maintained by the International School Health Network which as posted 219 resources in its school-focused bibliography/toolbox collection on school substance abuse. This ISHN collection also currently holds an equal number of selected research reviews and articles. As well, the ISHN collection is fed by a regular monitoring of over 150 journals, over 75 media outlets and over 75 social media sources. These resources are posted each day in a dedicated Twitter news feed on school substance abuse. The average number of items identified per month hovers around 50 new items per month.
Similarly, a search of the evaluated interventions for school-based interventions to prevent substance abuse that have been carefully selected from controlled trials and other similar sources by the Canadian Best Practices Portal found 38 interventions. This portal does not collect other resource materials, only the evaluated interventions, a far smaller universe from which to find items. Again, this is an unfavourable comparison for the CCSA database.
Database and Assessment of Local Initiatives
The purpose of this database was to collect examples of nominated local multi-intervention programs (initiatives) and then analyze them as they came in. As of October 15, no initiatives were posted in this database. It is our understanding that this part of the CCSA activity was not accomplished and in fact was stopped by CCSA.
This CCSA experience compares unfavourably with similar activities that we are aware of on other health issues. Many of these types of national projects undertake an environment scan to identify locally developed programs. These are often collected through web and telephone searches and then a list is published. For example, a comparable mental health project that CASH is involved with has collected over 80 local programs and listed them in relation to different aspects such as target audience, types of interventions, number of years operating, sources of funds etc. Of course, most of these lists become out of date very quickly and are dependent on having a funded person continue with the collection and posting. As well, many of the local programs are externally funded and often disappear when that funding is withdrawn.
The CCSA Web-based Television Series
According to the CCSA news release announcing its ten million dollar project, the CCSA web-based project had two components, a youth web site and a media/youth consortium of national media corporations and youth service organizations to develop and deliver evidence-based prevention messages to promote positive and healthy life choices for youth.
We will not be commenting on the web site for youth, except to say that it joins similar federally funded web sites published by Health Canada, the RCMP and the Canadian Anti-drug Strategy as well as numerous web sites published by provincial agencies and other organizations.
The web-based television series, URLTV, was an online healthy lifestyle television channel for Canadian youth aged 10–24. According to a CCSA newsletter, the URL-TV will blend information about substance use and its effects into youth programming focused on skill building, youth engagement and entertainment. The web site started publishing in the fall of 2010 and ended in the spring of 2011.
All links and references to the web TV activity have been removed from the CCSA and youth web site, and we could not locate any explanations for its ending. It was our understanding that the project was to receive funding from its media partners in order to keep going. It is difficult to assess the effectiveness of the short lived web television series, but given that it took three years to develop and six month at most to operate, it seems likely that this was an innovation did not succeed.
Lessons Learned from this CCSA Project
Making the shift away from the ‘old, traditional” approach to school-based prevention and health promotion is a very challenging task. The lens used to analyze the CCSA school standards document is very sharp and clear. A similar analysis of the Canadian research being funded and published was done in this newsletter several months ago and reported similar findings.
In truth, the CCSA document is not much different that the three similar documents published by Health Canada, the Canadian Association for School Health and the Joint Consortium for School Health. Like CCSA, those organizations conducted rapid research reviews and published general documents advocating comprehensive, multi-intervention programs and approaches through schools.
However, each of those documents was done for less than $50,000.00 and was not really intended to be more than what they were. Indeed, if one examines those three documents, one quickly finds that in many ways, the CCSA document duplicates the work in those previous documents. With a budget of $10 million over five years, we can and should expect more and better results.
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