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Health Promotion International Current Issue

Published: Wed, 05 Apr 2017 00:00:00 GMT

Last Build Date: Wed, 05 Apr 2017 09:43:57 GMT


Health Promoting Schools—a complex approach and a major means to health improvement


Development of health promoting schools in the European region

List of Reviewers


Health Promotion International would like to sincerely thank all reviewers who have given their time so generously in 2016 to this Journal, including:

Measuring health literacy in university students in Vientiane, Lao PDR


Health literacy includes the knowledge, motivation and competence of a person to make judgments and decisions on health information in order to promote and maintain their health in relation to health care, disease prevention and health promotion. The role health literacy plays in determining health outcomes makes it an important focus of public health research. In line with a larger Asia wide initiative (HLS-Asia), this study set out to measure health literacy in the Lao People’s Democratic Republic (Lao-PDR). A mixed-methods study design was employed. The HLS-Asia questionnaire was conducted as a self-administered survey with first year students at the National University of Lao PDR in Vientiane. The survey was complimented with in-depth, vignette style interviews. Student’s scores on the questionnaire showed problematic health literacy levels, with clear patterns to the type of questions students struggled with. However, responses in the interviews suggested a higher level of health literacy. These findings highlight the importance of health systems and social context in health literacy. The results question the appropriateness of the HLS measurement tool, but more broadly suggest that health literacy may be a concept only comparable between populations when social, economic and health systems are measured concurrently.

School-based primary NCD risk reduction: education and public health perspectives


The rising global burden of noncommunicable diseases (NCDs) has heightened awareness of the necessity for primary risk prevention programmes. These aim to facilitate long-term behaviour changes in children and adolescents that can reduce NCD risk factors and disease onset in later-life. School-based programmes designed to improve childhood and adolescent health behaviours and wellbeing contribute to this; however, design and impact assessment of these is complex. These programmes should be multidisciplinary, utilizing both educational and health expertise. Health outcomes may not be evident in the short term, but may occur with learning-related behaviour modifications, highly effective when sustained over a lifetime. Thus assessment must analyse short-term learning and behaviour impacts as well as long-term capability, behaviour and health outcomes.The focus of assessment measures in the health and education sectors differs and often lacks depth in one or other area. Educators generally focus on identifying evidence of learning related to capability, attitude and/or behaviour changes, while public health practitioners typically focus on health measures (e.g. body mass index (BMI), mental health, or risk behaviours).We argue that multidisciplinary approaches incorporating education and health viewpoints clarify issues relating to the potential value of schools as a setting to facilitate primary NCD risk reduction. To demonstrate this, we need to: 1) build stronger understandings of the features of effective learning for behavioural change and the best way to evaluate these, and 2) convincingly correlate these measures with long-term metabolic health indicators by tracking learner behaviour and health over time.

Validity and reliability of the South African health promoting schools monitoring questionnaire


Health promoting schools, as conceptualised by the World Health Organisation, have been developed in many countries to facilitate the health-education link. In 1994, the concept of health promoting schools was introduced in South Africa. In the process of becoming a health promoting school, it is important for schools to monitor and evaluate changes and developments taking place. The Health Promoting Schools (HPS) Monitoring Questionnaire was developed to obtain opinions of students about their school as a health promoting school. It comprises 138 questions in seven sections: socio-demographic information; General health promotion programmes; health related Skills and knowledge; Policies; Environment; Community-school links; and support Services. This paper reports on the reliability and face validity of the HPS Monitoring Questionnaire. Seven experts reviewed the questionnaire and agreed that it has satisfactory face validity. A test-retest reliability study was conducted with 83 students in three high schools in Cape Town, South Africa. The kappa-coefficients demonstrate mostly fair (κ-scores between 0.21 and 0.4) to moderate (κ-scores between 0.41 and 0.6) agreement between test-retest General and Environment items; poor (κ-scores up to 0.2) agreement between Skills and Community test-retest items, fair agreement between Policies items, and for most of the questions focussing on Services a fair agreement was found. The study is a first effort at providing a tool that may be used to monitor and evaluate students’ opinions about changes in health promoting schools. Although the HPS Monitoring Questionnaire has face validity, the results of the reliability testing were inconclusive. Further research is warranted.

The assessment of status of tobacco smoking among urban primary schoolchildren in Madagascar


The prevalence of tobacco smoking among adolescents aged 13–15 years old in Madagascar was previously reported to be higher than the average in other African regions. A preventive approach is urgently needed to avoid the initiation of early tobacco smoking. Therefore, the aims of this study were to evaluate the status of tobacco smoking among primary schoolchildren in Madagascar and explore the factors associated with initiation of tobacco smoking in the young. This study was conducted in the Mahajanga region of Madagascar. Three primary schools in this region and children of both genders between the ages of nine to 12 years old were randomly selected and approached to participate in this study. A self-administered questionnaire modified from the Global Youth Tobacco Survey Core Questionnaire 2007 was used to assess the status of tobacco smoking among primary schoolchildren. A total of 150 schoolchildren (14.0%) declared that they had smoked tobacco, with 30% starting to smoke tobacco at the age of seven or younger. The prevalence of tobacco smoking was lower among schoolchildren with non-smoking parents (p < 0.001) or non-smoking close friends (p < 0.001). Furthermore, schoolchildren’s antismoking intention (p < 0.001) and their knowledge about the harmfulness of tobacco (p = 0.009) had significant effects on the prevalence of tobacco smoking. The results of this study indicate that tobacco smoking among schoolchildren in Madagascar may be influenced by peers, or parents, as well as smoking intention and knowledge about the harmfulness of tobacco use.

Food environment and policies in private schools in Kolkata, India


School food policies and services have the potential to influence the food practices and eating behaviours of adolescents which in turn may affect their lifestyles and health in adulthood. The aim of this qualitative investigation was to describe the opinions of adolescents, their parents, nutrition educators and school principals about the prevailing food environment and canteen policies in Indian schools. Fifteen adolescents aged 14–15 years, 15 parents, 12 teachers and 10 principals from 10 private schools in Kolkata, India participated in semi-structured interviews. The interview questions were primarily based on the existing literature related to school food environments and policies. Audio recordings were transcribed verbatim and assessed thematically. Throughout the 52 interviews, a number of inadequacies of the school food environment and policies were revealed. These included the absence of written food policies, the widespread supply of unhealthy foods, inadequate provision of healthy foods, misleading messages about food communicated by school authorities, lack of cleanliness in the school canteen and the high cost of canteen food. Current school food environments do not appear to promote healthy eating among adolescents. Therefore, it is important to upgrade the quality of food services in Indian schools through adoption of healthy eating policies.

Policy windows for school-based health education about nutrition in Ecuador


The aim of this study is to identify opportunities in policy framing for critical health education (CHE) about food and nutrition in Ecuadorian schools. The research engages in a dialogue between the perspectives of critical nutrition and political ecology, as it seeks to clarify and develop a critical perspective on health promotion and health education. Critical nutrition studies and political ecology highlight the need to consider and also act upon the broader connections of, and influences on, food and nutrition. In a CHE approach, students learn to address the wider determinants of health through critical, democratic and collaborative processes, anchored in and supported by the local community. Based on a textual analysis of health, food and education policy documents, the study finds that concrete norms endorse a biomedical stance. Consequently, focus remains on prescribing individual behavior, and schools are regarded as intervention settings, rather than a site for generating change as would be the case of health promotion using a CHE viewpoint. However, the study finds the possibility for developing a CHE perspective in the overarching rationale of ‘good living’, which reaffirms a holistic understanding of health, the need for critical and plural participation and the importance of the community. It is possible that the notion of community participation could facilitate introducing a CHE approach in Ecuadorian schools.

Evaluating for impact: what type of data can assist a health promoting school approach?


There is debate within the health promoting school (HPS) movement on whether schools should monitor health behaviour outcomes as part of an evaluation or rely more on process type measures, such as changes to school policies and the physical and social environment which yield information about (in)effective implementation. The debate is often framed around ideological considerations of the role of schools and there is little empirical work on how these indicators of effective implementation can influence change at a policy and practice level in real world settings. Information has potentially powerful effects in motivating a change process, but this will vary according to the type of information and the type of organizational culture into which it is presented. The current predominant model relies on process data, policy and environmental audit monitoring and benchmarking approaches, and there is little evidence of whether this engages school communities. Theoretical assertions on the importance of monitoring data to motivate change need to be empirically tested and, in doing so, we can learn which types of data influence adoption of HPS in which types of school and policy contexts.

The picture of health: examining school-based health environments through photographs


Health-promoting schools (HPS) is an effective approach to enhance the health and well-being of children and youth, but its measurement remains a challenge considering contextual differences across school environments. The purpose of this study was to qualitatively explore the physical features of the school environment through photographs of schools that had implemented an HPS approach compared with schools that had not. This study used a descriptive approach, wherein physical features of the school environment were distilled through visual images and qualitatively analyzed. School environment data were collected from 18 elementary schools (10 HPS, 8 comparison schools) from a school board in rural Nova Scotia (Canada). Evaluation assistants captured photographs of the physical school environment as part of a broader environment audit. Overarching themes included the promotion, access and availability of opportunities for healthy eating and physical activity, healthy school climate and safety and accessibility of the school. The photographs characterized diverse aspects of the school environment and revealed differences between schools that had implemented an HPS approach compared with schools that had not. There were increased visual cues to support healthy eating, physical activity and mental well-being, and indications of a holistic approach to health among schools that implemented an HPS approach. This research adds to understanding the environmental elements of HPS. The use of photographic data to understand school environments provided an innovative method to explore the physical features of schools that had implemented an HPS approach.

Intersectoral collaboration to implement school-based health programmes: Australian perspectives


Understanding the processes and the factors influencing intersectoral collaboration is vital for the ongoing success of programmes that rely on effective partnerships between sectors, such as the school-based immunization programme, the school dental health programme and health promotion interventions delivered in school settings. We studied school-based health programmes delivered by partnerships between health, education and the local government sectors. We used purposive sampling to identify 19 people working in school-based health programmes and interviewed them about the barriers and enablers of successful collaboration. Data were analysed thematically. We found that collaboration between complex systems was a skilled endeavour which relied on a strong foundation of communication and interpersonal professional relationships. Understanding the core business, operational context and intersectoral point-of-view of collaborative partners was important both for establishing good intersectoral programmes and sustaining them as contexts and personnel changed. Aligning divergent sectoral agendas early in the collaborative process was essential for ensuring that all partners could meet their core business needs while also delivering the programme outcomes.

Systems thinking and complexity: considerations for health promoting schools


The health promoting schools concept reflects a comprehensive and integrated philosophy to improving student and personnel health and well-being. Conceptualized as a configuration of interacting, interdependent parts connected through a web of relationships that form a whole greater than the sum of its parts, school health promotion initiatives often target several levels (e.g. individual, professional, procedural and policy) simultaneously. Health promoting initiatives, such as those operationalized under the whole school approach, include several interconnected components that are coordinated to improve health outcomes in complex settings. These complex systems interventions are embedded in intricate arrangements of physical, biological, ecological, social, political and organizational relationships. Systems thinking and characteristics of complex adaptive systems are introduced in this article to provide a perspective that emphasizes the patterns of inter-relationships associated with the nonlinear, dynamic and adaptive nature of complex hierarchical systems. Four systems thinking areas: knowledge, networks, models and organizing are explored as a means to further manage the complex nature of the development and sustainability of health promoting schools. Applying systems thinking and insights about complex adaptive systems can illuminate how to address challenges found in settings with both complicated (i.e. multi-level and multisite) and complex aspects (i.e. synergistic processes and emergent outcomes).

School recess, social connectedness and health: a Canadian perspective


Children need opportunities to establish positive social connections at school, yet many school playgrounds are challenged by social conflict that can undermine these connections. When children's social needs go unmet, the resultant feelings of loneliness, isolation and self-doubt can cumulatively lead to mental and physical illness. Because recess is typically the only time during the school day that children are free to socialize and play, we propose a more thoughtful way of thinking about it: from the lens of belongingness. Schools are, historically, designed for instruction. We argue, however, that we need to attend to children's social needs at school. We highlight current research from social neuroscience, belonging and social connectedness in order to delineate the pathways between daily school recess and developmental health trajectories. We then consolidate an array of research on play, social interaction and school change to suggest four areas that could benefit from consideration in research, practice and policy: (i) the culture of recess, (ii) the importance of healthy role models on the playground, (iii) the necessity of activities, options and variety during recess and (iv) the significance of space and spatial layout (indoor and outdoor). We bridge our discussion with the conception of health as described in the Ottawa Charter and emphasize the need to build alliances across sectors to assist schools in their efforts to support children's overall health needs.

The impact of a Portuguese middle school social–emotional learning program


This controlled pre–post study investigated whether a universal, school-based, social–emotional learning program implemented in two consecutive school years in two distinct cohorts, would promote gains in the social–emotional competencies of Portuguese middle school students. Moreover, it also analyzed the moderating role of students' characteristics, such as gender and baseline levels, on the impact of the intervention. Program ‘Positive Attitude’ was applied to 472 seventh to ninth grade students (25 classes). One hundred and fifty-six students in control groups (8 classes) also participated in this study. Overall, there were 628 participants aged from 11 to 17 years (Mage = 13.54; SD = 1.36). Self-report questionnaires were administered before and after the intervention. There were significant intervention gains in three (of five) social–emotional competencies, namely increases in social awareness and self-control as well as decreases in the levels of social anxiety in the first cohort. The positive effects were stably effective in the second cohort, except for social anxiety. Girls revealed greater gains in social awareness and greater reductions of the levels of social isolation and social anxiety when compared with boys. Intervention students with lower social awareness pretest scores profited more than controls. These results indicated that the intervention improved the social and emotional competencies of middle school students, supporting the cross-cultural generalization of social–emotional learning programs' efficacy.

Associations of health behaviors, school performance and psychosocial problems in adolescents in The Netherlands


School-based health-promoting interventions show promising results in improving various health outcomes of adolescents. Unfortunately, much is still unknown about the relations between health behaviors and school performances, while improving these would give schools a stronger incentive to invest in health promotion. This paper presents the associations of several health behaviors with school performances and studies the mediating effects of psychosocial problems. Health behavior and socio-demographic data were gathered from 905 Dutch high school students via an online survey, completed in-class. These data were matched with school records of the students' overall grade average (GA) on the three core subjects in Dutch high schools (Dutch, English and Math). The associations between health behaviors and school performances, and the potentially mediating effects of psychosocial problems, were studied via mixed-effects regression models. Smoking, being bullied, compulsive and excessive internet use and low physical activity were directly associated with lower school grades. Additionally, being bullied, bullying, smoking, excessive and compulsive internet use were associated with students' grades via mediation of psychosocial problems. This means that lower school grades were (also) associated with those behaviors through the effects of psychosocial problems in those students. This study showed the strong links between health behaviors and academic achievements among adolescents. Schools and health promoters should be educated more on these relations, so that they are aware of this common interest to get more support for health-promoting interventions. Additionally, the role of psychosocial problems in the relations between behaviors and school performances should be studied further in future research.

Effects of the School for Health network on students' behaviour in Asturias (Spain)


From 1995, Asturias participates in the European Network of Schools for Health (SHE); in 2010, the schools in net were 44 (11 of secondary school). This study evaluates the effect of SHE in secondary school students’ behaviour. A quasi-experimental study was conducted with four public SHE and four non-SHE-schools; the study population consisted of the first- and fourth-year students. By questionnaire, data on socio-demographics, the school environment, well-being and behaviours were collected. In the intervention group (the SHE-schools), the percentage of students who declared that their school engaged in health activities was significantly higher. Among the first-year students, the percentages of children having breakfast daily, occasionally eating pastries and occasional consumption of soft drinks were significantly higher in the control group; among the fourth-year students, the percentages of children reporting high school satisfaction, good relations with teachers, good academic performance, no alcohol use, never having been drunk and collaboration in housework were significantly higher in the intervention group. Significant gender differences were observed among the first-year students in both groups with boys consuming more hours of electronic entertainment; among the fourth-year students, the perception of school performance was significantly better for girls, while weekly physical activity, daily breakfast and high self-esteem were more prevalent among the boys. The results suggest a positive effect of the SHE programme, because differences among the first-year students favouring the control group were not present among the fourth-year students, while the intervention group showed significantly better results in 6 of 25 compared outcome variables.

Child mental-health policy development in sub-Saharan Africa: broadening the perspectives using Bronfenbrenner's ecological model


Despite socio-economic, demographic and epidemiological facts and realities that point to a potential risk for explosion in the prevalence of childhood mental health problems in sub-Saharan Africa, there is still a severe dearth of child and adolescent mental health (CAMH) policy or strategy to respond to the situation in the region. Unfortunately, current attempts at suggesting courses of action in this regard appear to be focused on narrow reactionary approaches. There is a need for theoretical frameworks to capture the full ramification of childhood in sub-Saharan Africa, from which multi-level, context-appropriate and holistic CAMH policy directions can be understood. In this commentary, we propose an amended version of the Bronfenbrenner's ecological model of childhood as such framework that captures proximal, intermediate and distal factors that influence the care environment of children. We then used the insights provided by the model to identify and prioritize intervention points and appropriate intervention strategies in charting a tentative course for CAMH policy development in the region. Though the ecological model provides a distinct perspective to the structure and dynamics of the care environment of children, the proposed framework using the model is still largely theoretical and need to be further integrated into future studies on CAMH policy development in the region.

Lessons from a peer-led obesity prevention programme in English schools


Obesity in young people is a major public health concern. Energy balance, the interrelationship between diet and physical activity, is known to be a key determinant. Evidence supports the development of school-based approaches to obesity prevention. ASSIST (A Stop Smoking in Schools Trial) is an effective school-based, peer-led smoking prevention programme for 12–13-year-old students, based on diffusion of innovations theory. The AHEAD (Activity and Healthy Eating in ADolescence) study tested the feasibility of adapting ASSIST to an obesity prevention intervention. The AHEAD intervention was tested and refined during a pilot study in one school, followed by an exploratory trial in six schools. Quantitative (self-report behavioural questionnaires and evaluation forms) and qualitative (structured observations, focus groups and interviews) research methods were used to examine the implementation and acceptability of the intervention. The potential effectiveness of the intervention in increasing healthy eating was measured using self-report behavioural questionnaires. Activity monitors (accelerometers) were used to measure physical activity. Results show it was feasible to implement the AHEAD intervention, which was well received. However, implementation was resource and labour intensive and relatively expensive. Furthermore, there was no evidence of promise that the intervention would increase physical activity or healthy eating in adolescents. Although diet and physical activity are both relevant for obesity prevention, the focus on two behaviours appeared too complex for informal diffusion through peer networks. This identifies a tension, particularly for adolescent peer-led health promotion, between the desire not to isolate or oversimplify health behaviours and the need to present clear, succinct health promotion messages.

Implementation practices in school health promotion: findings from an Austrian multiple-case study


Since the 1980s, schools have been recognized as an ideal setting to promote students' and teachers' health. Three decades after the development of the Health Promoting Schools (HPS) approach, however, there is still only limited knowledge about the implementation of health promotion (HP) activities in this setting. Some studies indicate that schools change original concepts significantly when adapting them to local context in the course of implementation. In this paper, we pursue the question how HP is practiced in schools that have agreed to implement HPS concepts from regional service providers (SPs), using data from a multiple-case study conducted in an Austrian province. Furthermore, we explored the HP activities chosen for implementation and the decision-making leading to their implementation. We draw on 22 interviews with members of the school community and provincial HP SPs, 9 group discussions, and 10 observations we have carried out within three schools between November 2010 and January 2012, supplemented by a variety of documents. We have identified 40 different HP activities, of which most targeted students, while mostly focusing on physical activity and/or psychosocial health. Planning, coordination and cooperation at the school level were minimal. Decisions for or against activities were seldom taken together, but taken individually due to personal knowledge, interests and experiences, perceived needs and problems, already existing activities and external influences. The findings suggest that schools rather remain with a traditional topic-based approach instead of realizing an integrated whole-school approach and indicate a need for more support especially during the early phases of implementation.

Physically active Chilean school kids perform better in language and mathematics


We examined the association between the engagement in regular physical activity (PA) and the academic performance (AP) of school-age children from Santiago Metropolitan Region. In a random sample of 1271 students (13.3 ± 2.3 years old) we measured regular PA, accounting for hours of weekly scheduled exercise, and AP, using national standardized tests scores in Language and Mathematics. Bivariate and multivariate regression analyses were used to model the relation between academic and health-related behaviors. Two outcomes were considered: (i) sufficiency according to the Ministry of Education and (ii) discretionary sufficiency (tests z-scores ≥50th percentile). About 80% of students were poorly engaged in scheduled exercise (<2 h per week). Devoting more than 4 h per week to scheduled exercise significantly increased the odds of reaching the official and discretionary sufficiency in both Language and Mathematics. Moderate engagement (2–4 h per week) just improved the odds of reaching the discretionary sufficiency standard. These results confirm the poor engagement in regular exercise at the school level. School kids with the highest allocation of time to scheduled exercise have better AP in Language and Mathematics. Our findings support the notion that academic and health-related behaviors are linked and, similarly, that school health programs may have positive effects on educational outcomes.

Effects of student participation in school health promotion: a systematic review


The aim of this systematic review was to summarize systematically the existing evidence for the effects of student participation in designing, planning, implementing and/or evaluating school health promotion measures. The focus was on the effects of participation in school health promotion measures rather than on student involvement at school in general. Participation is a core value for health promotion but empirical evidence of its outcomes is scarce. We searched major bibliographic databases (including ASSIA, ERIC, PsycINFO, Scopus, PubMed and the Social Sciences Citation Index). Two reviewers independently decided about inclusion and exclusion of the identified abstracts (n = 5075) and full text articles. Of the 90 full text articles screened, 26 papers met the inclusion criteria. We identified evidence for positive effects, especially for the students themselves, the school as organization, and interactions and social relations at school. Almost all included studies showed personal effects on students referring to an increased satisfaction, motivation and ownership, an increase in skills, competencies and knowledge, personal development, health-related effects and influence on student perspective. Given that student participation has more been discussed as a value, or ideal of health promotion in schools, these findings documenting its effectiveness are important. However, further research is needed to consider the level or intensity of involvement, different approaches and stages of participation in the health promotion intervention, as well as mediating factors such as gender, socio-cultural background or academic achievement, in a more systematic manner.

Health promotion in Swedish schools: school managers' views


Schools are recognized worldwide as settings for health promotion, and leadership has a bearing on schools’ ability to be health promoting. School managers have a great influence on what is prioritized in school, which in turn affects students’ school performance and health. There is lack of research into school managers’ views on health promotion, and what they consider to be central to health promotion. The aim was therefore to examine school managers’ views about what health promotion in schools include. An explorative design, qualitative content analysis, was performed. In-depth interviews were conducted with all 13 school managers of a middle-sized municipality in central Sweden. The analysis had both manifest and latent content and three categories: ‘Organization and Collaboration’, ‘Optimize the arena’ and ‘Strengthen the individual’, and 10 subcategories emerged. The theme, ‘Opportunities for learning and a good life’, describes the latent content of these categories. Taking into account the views of school managers are important because these views help form a more complete picture of how school managers work with health promotion and what is needed to enhance health promotion to improve students’ opportunities for learning and a good life. The Ottawa Charter for Health promotion is thereby transformed into practice.

Culture matters: a case of school health promotion in Canada


Rising concerns of poor health behaviours of children and youth have stimulated international support for a comprehensive approach to promoting the development of healthy behaviours in the early years. Health promoting schools (HPS) is increasingly adopted as an approach to guide supportive practices, but there is limited research that has reported how to effectively implement HPS at a population level. The purpose of this research was to qualitatively explore the factors preventing and facilitating implementation of HPS practices in the Canadian province of Nova Scotia. Interviews (n = 23) were conducted with school stakeholders (principals, teachers and parents) from a diverse sample of schools (n = 9) and data were analysed to develop an understanding of how school circumstances and experiences influenced HPS implementation. At a broad level, the reported barriers were structural and systemic, whereas the facilitating factors were related to organizational capacity and political leadership. It was evident that implementing and sustaining HPS required a shift in values and integration of supportive school health practices into school priorities. The results suggest that, without addressing the competing culture, which is persistently reinforced by strict academic mandates and unhealthy community norms, HPS will be vulnerable to circumstances that prevent implementation. Considering the emerging importance of mental wellbeing, it will also be important to provide schools with adequate and appropriate staff capacity and support to address this issue. Sustaining the positive effects of HPS will require continuous engagement and collaboration with multiple stakeholders to embed health promotion into school community norms.

Evaluating school-community health in Cyprus


This article presents results from the Cypriot experience of participation in a pan European health promotion project called ‘Shape Up’. Implemented between September 2007 and June 2008, the aims of the overall programme reflect the primary concern of health promotion to facilitate healthy choices by creating the necessary conditions for their enactment. We describe the processes used in Shape Up before reporting findings from the evaluation undertaken by the University of Hull, UK. Findings from the Cypriot case studies demonstrate schools’ potential to work in health promoting ways by enabling school communities to create environments conducive to health, where individuals are better able to take care of their health rather than simply implementing healthy activities at school. Participants in Shape Up Cyprus increased their access to healthier foods and opportunities to be active during and after school. Apart from visible environmental changes, participants were equipped with skills and critical knowledge to be healthier and more active citizens. They investigated the wider determinants of health and options for health improvement in specific contexts. They identified what needed changing within and around the school, developing visions of how changes could be enacted. They transferred visions into actions by writing letters, undertaking research, developing networks and accessing advice and financial support. We conclude that increasing awareness of the impact of structural factors upon health and the acquisition of skills in community action were central to Shape Up's success in Cyprus, and are therefore relevant for school-based health promotion.