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A Road Map for School Health Promotion, a Model for Cognitive-Oriented School Health Policy Making and Implementing Policies for Schools

Background: School health promotion programs implemented in different countries have experienced varying degrees of success. Their success rate depends on various factors such as adaptation with the local charactristics of communities. Objectives: This paper aims to provide an experimental model for school health policy making in a large group of non-governmental schools in Iran. Materials and Methods: To institutionalize school health policies, appropriate organizational structure was established at the headquarters. The road map as “SAMA school health program” was developed in cooperation with the committee of experts and engaging stakeholders. This program was adopted and notified by the health policy council. Results: The main output of this process was compiled in the 36-pages book which has been published and distributed in all of Islamic Azad schools branches. Conclusions: Both structural and the process issues were considered in this template. Engaging policy makers and service providers to make a commitment to the program was the effective intervention for this policy making process. But a low priority of health programs in a notable proportion of school managers, lack of budget and a major obstacle to the implementation of human resources policies remain as the main limitations of our model considered to improve school health promotion.


Background
Schools are important gathering places for a large group of people. Health promotion in schools has been of great concern for health professionals from the earliest time due to the presence of children and adolescents in this environment.
To date, several organizations, as scientific institutions, formed since 1927 have been engaged to address problems related to health promotion issues. American school health association was formed to involve doctors in the school health, and contribute to school health policy making (1).
In parallel with the development of school health promotion programs, European network for School health promotion formed in 1980 became one of the most important health policy-making bodies in schools in Europe with members from 43 countries (2).
Australian school health association began to work from 1994 and has been responsible for health policy programs in schools (3). School health office in Iran was established in the ministry of Education in 1935.
In 1981 the school health office was merged with the office of maternal and child health in the ministry of health, generally called the office of family health and the schools, which was responsible for providing health services to students. The office of nutrition and school health coordination was established in the Iranian ministry of education in 1990 due to an urgent need for health care in schools. Various models on school health system development have been introduced globally. School health promotion model announced by the world health organization (4) have been exploited and its efficiency in health promotion in schools were evaluated in a number of countries with generally promising results (5,6).
However several theoretical frameworks to improve school health and proposed previously mainly consider the school environment, personality characteristics of learners and their behavior as the determinants of school health (7).
It is necessary to retranslate the school health models according to local and regional characteristics of each society. Even the allocation of funds through public or pri-vate sectors should be considered in this reengineering. Despite the stability in the main concepts of the model, there is some difference in its application in regard to the public and private schools.
Islamic Azad schools organization, abbreviated as "SAMA" in Persian, plays greatest educational role as the non-governmental schools chain in Iran, where about 650 schools are the members of this chain and are responsible for education of about 60,000 students across the country (8).
Diversity of activities in SAMA and consequently the need for integration of different policies, make it necessary for SAMA to have a proper model for policy making in various fields such as education and school health etc.

Objectives
Accordingly, the authors have tried to provide a model for school health policy making model based on the key concepts of health promoting schools. This model of policy making may be useful for other non-governmental organizations operating in several schools.

Organization Reengineering and Levels of Policy Making
To promote health policy in schools of SAMA, The first step taken was to reengineer and create new structures for health policy making.

SAMA Health Policy Council
The council which meets once every 3 months to review and approve school health policies is the highest policymaking body in SAMA school health. It consists of SAMA president, acting chancellor of Islamic Azad university in medicine, vice chancellor of medical sciences, vice chancellor of education and the head of school health office, joined by two experts in the field of school health.

Health Administration Council
The council was formed as the auxiliary policy council and consisted of head of SAMA office of school health, secretary of strategic council of medical sciences at IAU, director of the SAMA health and physical education and two experienced school nurses. Its members are appointed by the president of SAMA. This council is responsible for implementing the approved health policies in schools.

SAMA Office of School Health
SAMA office of school health was organized under the supervision of SAMA deputy of education in order to manage administrative ineractions in the field of school health with three subsets comprising health education, health services and environmental health.

Developing Road Map
Developing a comprehensive school health road map with special requirements of the SAMA based on past experiences and in line with key concepts of health promoting school model (HPS) was the first phase after organizational restructuring, and included the following steps:

Expert Panel Formation and Preparing Primary Draft
To develop a road map, an expert committee of five members, including 3 physicians with experience of working in schools, a school nurse and a statisticion was formed for preparing the initial draft of roadmap. Health promoting school model (HPS), national guidelines in school health and other documented evidences were used for designing this roadmap (9)(10)(11). Three levels of planning were considered according to model of national comprehensive s science map that included objectives, strategies and actions (12).
Major objectives considered in this roadmap were based on national and global health priorities including empowering students to promote a healthy lifestyle. This was achieved by an emphasis on improving nutrition and physical activity, reducing the lost hours of education because of health disorders, improving the effectiveness of educational activities through improving academic environmental health and promoting health status of teachers and school staff.
After the initial compilation, the first version of the roadmap was prepared in the form of a manual (13).

Feedback From Stakeholders
To improve the component of this road map and commitment to its implementation, SAMA school health conference was held by school health professionals and attended by about 130 members from peripheral units and schools.
The importance and the process of developing a road map were explained in 3 hours. The participants were then given 120 minutes to present their views about the map. Also they were given two weeks to submit in writing their comments on the map. In general, participants did not provide any new proposal to edit this roadmap.

Health Policy Approval
In order to attract the support of policymakers, the road map was revised by the expert committee in regard to some comments and submitted to health policy council for evaluating the contents of the map in a 60-minute session and approved as SAMA upstream policy in school health.

Affiliated Schools and Units
Following approval by the health policy council, the road map was delivered to peripheral units and schools accompanied by a letter from the SAMA president as upstream policy in school health to be considered in all relevant policies and programs.

Results
The main output of this process is the 36-pages book which has been published and distributed in all branches of SAMA. This book contains mission and vision statement, 4 major objectives, 15 related strategies and 88 actions developed by the committee in order to achieve its major objectives. Also the digital format of this book has been uploaded in the SAMA webpage.

Discussion
SAMA school health program as a strategic plan for health promotion in the SAMA was the main output of this intervention.
Today's major plans developed through the road map, are an essential managerial tool in the various fields which by collective thinking help policy makers take more efficient steps for health promotion.
Developing road map in various fields of industry and services has been used as an effective planning method (14)(15)(16)(17). On the other hand, organizing and establishing organizations to implement policies and programs of the road map are necessary for attaining the associated goals (18). Accordingly, the organizing of councils and office of school health by SAMA seems to be an effective step in achieving the desired objectives.
The main strength of the road map developed by SAMA was interaction with and getting feedback from stakeholders who were offered the map. Based on existing experience, this approach could commit the stakeholders to contribute to the program involving policy-makers and service providers (19,20). Among the limitations of this model, was lack of familiarity with the concept of school health, notably in considerable number of school principals. Some managers consider school health programs less important than other programs such as educational programs. This challenge is a serious obstacle in the implementation of policies formulated at the school level.
Another important limitation of SAMA is funding sources for implementation of policies.
The SAMA schools are private which are dependent on students for tuition and popular donations as financial support, in the face of serious difficulties in securing budget for many health programs in schools. Meanwhile, there are little administrative budget for the implementation of these programs in peripheral units and schools Lack of human resources is another limitation for the implementation of the road map in schools where about 40% of schools do not have such resources.
It is noteworthy that attracting public support and collaboration of parents who participated in roadmap are some solutions to this problem.
Finally it is concluded that we far from full realization of the programs and to improve students' health, which calls for collective efforts to access operational plans in regard to the road map. In addition, further studies are needed to design appropriate methods and protocols for evaluating the effectiveness of the roadmap.
This model of policy making and planning seems to be useful for school chains and even for more general policymaking bodies such as the department of education in different countries.

Acknowledgments
Authors must acknowledge all of central and peripheral staffs who cooperate with our team in order to prepare this manuscript.
Funding/Support:Authors have benefited from official support of Islamic Azad schools organization (SAMA).