TY - JOUR
AU - Jimba, M
AB - Abstract Thailand formulated a National School Health Policy (NSHP) in 1998, and it has been widely implemented but has not been evaluated. This case study aimed to identify factors that have influenced the implementation of NSHP in Thailand. For this purpose, we conducted a document review and key informant interviews. We selected key interviewees, from NSHP implementers at national, provincial and school levels in four geographical areas. We adopted a content analysis method, using a framework of 12 influential components of successful policy implementation and triangular policy framework. This study showed that NSHP was well-disseminated and implemented at whole country. We identified seven positive factors influencing NSHP implementation, namely matching with ongoing educational strategy, competition and encouragement by an awarding system, sustainable human capacity building at school level, participation of multiple stakeholders, sufficient understanding and acceptance of school health concepts, sharing information and collaboration among schools in the same clusters and functional fund raising activities. In addition, we identified three negative factors, namely lack of institutional sustainability, vague role of provincial officers and diverse health problems among Thai children. The government should clarify the role of provincial level and set up institutionalized capacity-building system as measures to strengthen monitoring and evaluation activities. Introduction The school setting is one of the strategic places to deliver health and development messages to children, parents, and teachers [1]. Traditionally, schools have hosted health education to build health knowledge, skills, and behaviours [2]. However, health education approaches have not been fully successful in reducing risky health behaviours among schoolchildren [2]. To overcome such constraints, the World Health Organization (WHO) introduced the concept of ‘Health-Promoting Schools (HPS)' [3]. The HPS has five components, namely school health policies, skills-based health education, health services, psychosocial health, and the physical environment. The HPS concept had been subsequently adopted and implemented globally [3]. Several developing countries formulated national school health policies (NSHP) based on the HPS concept. For example, Laos formulated a NSHP in 2005 [4], Nepal in 2006 [5], Nigeria in 2006 [6], and Kenya in 2009 [7]. Furthermore, Niger and Singapore introduced self-assessment approaches to improve school health activities at the national level [8, 9] and made advances in health-related activities in schools. However, less attention has been paid to the factors influencing NSHP implementations. Four conditions were previously identified to achieve HPS application in Europe: comprehensive and integrated intervention, school/family/community partnerships, political and financial support from policy makers, and evaluation research [10]. Another study in South Africa identified sufficient human resources, availability of transportation to schools, and advanced training as factors for successful NSHP implementation [11]. However, these previous studies did not target implementers at all administrative levels. Although evidence is limited, a case study in Hong Kong targeted implementers at all administrative levels and the study indicated the importance of joint efforts by both the education and health sectors for successful NSHP implementation. Besides, the study clarified the essential factors in successful programs, namely teacher training, curriculum development, community participation, changes to policies and practices, and research [12]. A case study in Laos identified influential factors for NSHP implementation, including extensive planning with a clear long-term vision at national level, human resource management through well-organized training at each level, and a monitoring cycle to understand the situations in schools [13]. In Thailand, a middle-income country in South-East Asia, HPS has been successful. The net enrolment rate of primary schools reached over 95% in 2008 [14]. The Thai government introduced HPS in 1998 and disseminated this concept nationwide [15]. The Ministry of Public Health (MOPH) has taken the initiative of the implementation and established implementation guidelines. Additionally, in 2000, the MOPH introduced an awarding system, which had three levels of rating, namely bronze, silver and gold. The number of ‘gold’ level schools dramatically increased over a short period, from 8.9% in 2003 to 40.3% in 2007 [16]. In 2008, because almost all schools had achieved good school health, the ‘diamond’ level was introduced as the highest level [17]. However, recently, child obesity and early pregnancy have arisen as new health issues [18, 19]. Therefore, it is necessary to promote NSHP more to resolve these issues. To cope with new health threats, factors influencing its nationwide implementation should be identified but it has not been well studied in Thailand. Thus, this study aimed to identify factors that influenced the implementation of NSHP at national, provincial and school levels in Thailand. Materials and methods This study applied a case study approach [20, 21] to understand implementation dynamism and key factors from various aspects. From February to August 2011, we collected data from two main sources: key informant interviews and document reviews. Key informant interviews We conducted key informant interviews with 19 NSHP implementers who provided information about their first-hand experience at national, provincial, and school levels in four areas of Thailand (northern, north-eastern, central and southern). We defined as NSHP implementers (i) government officers who belonged to national or provincial school health-related departments, or health teachers responsible for school health activities under the Office of the Basic Education Commission (OBEC) or local authorities, and (ii) individuals who had significant roles in the process of NSHP implementation at their level. We selected key informants using a purposive sampling strategy at each administrative level. At the national level, we chose two interviewees from the MOPH and one interviewee who had retired from the Ministry of Education (MOE) in 2007. At the provincial level, we first selected four provinces based on accessibility to researchers in four geographically divided areas of Thailand: (i) Khampheangpet in the northern area, (ii) Nakhon Ratchasrima in the northeastern area, (iii) Suphanburi in the central area and (iv) Songkhla in the southern area. We conducted all interviews for national and provincial level at their office. Then, we chose one interviewee from the education and health sectors in each province. At the school level, we chose two primary schools in each selected province: one with good achievement and another with limited achievement in NSHP implementation, as indicated by a school health coordinator at the provincial education office. Then, we chose one health teacher in each selected school. We conducted all interviews of school level at their school. We developed an interview guide by modifying the ‘policy implementation assessment tool for implementers and other stakeholders’ of the United States Agency for International Development (USAID). USAID’s interview guide covers the overall process of health policy implementation, and several low- and middle-income countries apply this guide in their health policy analysis [22]. After translating open-ended questions in this guide from English to Thai, we discussed the validity of each question with experts from both education and health sectors, and then, revised questions based on their comments and suggestions. The research teams consisted of one or two researchers from Japan and two researchers from Thailand who had school health backgrounds. We did not include the researchers who worked at target offices in research members to minimize influences to the interviewee’s responses. We conducted interviews in Thai language, and each interview took three to four hours. After the interviews, we transcribed all responses in Thai, using notes and digital records, and then, we translated them into English. Document reviews We reviewed documents related to NSHP implementation, which had been obtained from the interviewees. We also collected NSHP-related documents by searching PubMed, EBSCO, Google and Google Scholar. Reviewed documents included published research papers, health promoting implementation manuals, national reports about school health survey, official reports regarding school health by the MOPH in Thailand and school textbooks used in primary schools. Data analysis We adopted a content analysis method using a framework consisting of twelve influential components of successful policy implementation [23]. First, we categorized interview responses into the twelve components and created new narratives based on the categorized data. Second, we compared the categorized data of all levels (national, provincial and school) and sectors (health and education) to examine the common and specific patterns among levels/sectors. We triangulated insights from key informant interviews with document reviews. Third, we identified specific factors based on the interpretation of the data. Finally, we classified these factors into four policy design elements that comprised the ‘triangular policy framework’ for health policy reform and implementation: (i) process, (ii) actors, (iii) content and (iv) context [24]. To ensure rigor and quality, three researchers conducted the data analysis and other research members consulted on the analysis regularly. This research was a collaboration work among the Japan Consortium for Global School Health Research (JC-GSHR) and the faculty of tropical medicine, Mahidol University. The Memorandum of Understanding (MOU) was entered into by and between the both sides in September 2012, which describes collaboration research in school health policy development and implementation in Asia. As some JC-GSHR members belong to The University of Tokyo, research approval was obtained from the research ethics committee at The University of Tokyo. Before the interview, we informed all participants about the purpose and procedure of the study and we obtained written informed consent from each participant, both for participation and for the recording of interviews. We conducted recordings within the boundaries of confidentiality agreed to at the time of interviews. Participants could choose to refuse or discontinue participation at any time. Results The NSHP was well disseminated and implemented at all administrative levels. However, all key informants reported that the quality of school health activities could be much more improved. As for factors influencing NSHP implementation, we identified seven positive and three negative factors, and classified them into four elements, namely process, actors, contents and context. Table I summarizes 10 factors categorized by elements and administrative levels. Table I. Factors categorized by elements and administrative levels Elements  Factors  National  Provincial  School  Process  +  1. Matching with ongoing educational strategy and SHN activities  ✓  ✓  ✓  +  2. Competition and encouragement by an awarding system  ✓    ✓  -  3. Lack of institutional sustainability atadministrative level  ✓  ✓  ✓  Actors  +  4. Sustainable human capacity building at school level      ✓  +  5. Participation of multiple stakeholders  ✓  ✓  ✓  -  6. Vague role of provincial officers  ✓  ✓  ✓  Contents  -  7. Diverse health problems among Thai children  ✓    ✓  Context  +  8. Sufficient understanding and acceptance of school health concepts  ✓  ✓  ✓  +  9. Sharing information and collaboration among schools in same cluster      ✓  +  10. Functional found raising activities  ✓  ✓  ✓  Elements  Factors  National  Provincial  School  Process  +  1. Matching with ongoing educational strategy and SHN activities  ✓  ✓  ✓  +  2. Competition and encouragement by an awarding system  ✓    ✓  -  3. Lack of institutional sustainability atadministrative level  ✓  ✓  ✓  Actors  +  4. Sustainable human capacity building at school level      ✓  +  5. Participation of multiple stakeholders  ✓  ✓  ✓  -  6. Vague role of provincial officers  ✓  ✓  ✓  Contents  -  7. Diverse health problems among Thai children  ✓    ✓  Context  +  8. Sufficient understanding and acceptance of school health concepts  ✓  ✓  ✓  +  9. Sharing information and collaboration among schools in same cluster      ✓  +  10. Functional found raising activities  ✓  ✓  ✓  +: positive factors; −: negative factors. Table I. Factors categorized by elements and administrative levels Elements  Factors  National  Provincial  School  Process  +  1. Matching with ongoing educational strategy and SHN activities  ✓  ✓  ✓  +  2. Competition and encouragement by an awarding system  ✓    ✓  -  3. Lack of institutional sustainability atadministrative level  ✓  ✓  ✓  Actors  +  4. Sustainable human capacity building at school level      ✓  +  5. Participation of multiple stakeholders  ✓  ✓  ✓  -  6. Vague role of provincial officers  ✓  ✓  ✓  Contents  -  7. Diverse health problems among Thai children  ✓    ✓  Context  +  8. Sufficient understanding and acceptance of school health concepts  ✓  ✓  ✓  +  9. Sharing information and collaboration among schools in same cluster      ✓  +  10. Functional found raising activities  ✓  ✓  ✓  Elements  Factors  National  Provincial  School  Process  +  1. Matching with ongoing educational strategy and SHN activities  ✓  ✓  ✓  +  2. Competition and encouragement by an awarding system  ✓    ✓  -  3. Lack of institutional sustainability atadministrative level  ✓  ✓  ✓  Actors  +  4. Sustainable human capacity building at school level      ✓  +  5. Participation of multiple stakeholders  ✓  ✓  ✓  -  6. Vague role of provincial officers  ✓  ✓  ✓  Contents  -  7. Diverse health problems among Thai children  ✓    ✓  Context  +  8. Sufficient understanding and acceptance of school health concepts  ✓  ✓  ✓  +  9. Sharing information and collaboration among schools in same cluster      ✓  +  10. Functional found raising activities  ✓  ✓  ✓  +: positive factors; −: negative factors. Process Two positive factors, namely matching with ongoing educational strategy, and competition and encouragement through the awarding system, contributed to making the school health activities routine among schoolteachers. In contrast, the lack of institutional sustainability undermined the consistency of school health activities as described in the following. (a) Positive factors Matching with ongoing educational strategy School principals reported that school health activities have been embedded in ongoing educational strategies at school level. Therefore, the activities had been integrated in school management action plan. Evaluation report by Thai government also mentioned the linkage of NSHP with educational standard and curriculum and recommended the directors to accept school SHP as one of the school’s policy [25, 26]. Thanks to this integration and government policy support, schoolteachers could conduct school health activities as part of their daily tasks. Competition and encouragement through the awarding system School principals indicated that self-assessment checklist was helpful to decide activities to be prioritized. According to national level officers and teachers, the awarding system worked as a competitive mechanism, and encouraged both schools and communities. Thai government indicated clearly required school health activities in the checklist and evaluated by awarding system [26]. However, in 2008, the awarding system changed; the annual awarding system was cancelled and changed to an occasional certificate-style award system, in which schools could no longer receive monitoring and evaluation from the government, and only declared their achievement to get certification. (b) Negative factor Lack of institutional sustainability at the administrative level At the beginning of NSHP implementation, both the education and health sectors had established MOU and well collaborated between them [26]. However, changes of influential administrators inhibited policy implementation at all levels. According to a MOE officer, after the retirement of one MOE administrator, who was a strong opinion leader, in 2007, the leadership by MOE, as well as coordination gradually became weaker. She also reported the need for human resource development at the administrative level to secure institutional sustainability. Moreover, school principals mentioned the lack of consistency of strategy and priority on school health activities due to frequent transfers of school principals. Actors Two positive factors contributed to promoting school health activities in schools. In contrast, we identified the vague role of provincial officers as a negative factor. (a) Positive factors Sustainable human capacity building at the school level Every Thailand school appoints at least one responsible teacher for school health activity [26]. Any teacher can apply to be a school health teacher and receive short-term training from provincial officers. School health teachers regarded the training as effective because of the practical contents and applications, and felt very confident about implementation because they had acquired not only knowledge but also the ability to plan school health activities logically on their own. Moreover, in the training course, teachers learn the NSHP concept, importance of the teacher’s role, role of the trainee and importance of cooperation with a school principal. In addition, schoolteachers indicated that the implementation guidelines were widely disseminated,understandable and practical. At the national and provincial levels, officers considered the guidelines to be user-friendly. Indeed, the government has provided continual training and guidelines for school health teachers and students [26]. Participation of multiple stakeholders At the national level, both the MOE and MOPH have played a specific role. Provincial and school level implementers perceived that the MOU between the education and health sectors had a positive impact on the collaboration. In addition, various private companies have provided not only financial assistance but also technical assistance from the beginning of the implementation. At the school level, schools have involved multiple stakeholders, including village authorities, community clubs, parents and teachers’ associations, school management committees, local municipalities, temples, sub-district administrative organizations, district health offices, community hospitals and so on. They have supported school health activities financially, technically and politically. In particular, health-promoting hospitals, which are the lowest-tier health facility in Thailand, have played an important role in schools. Hospital nurses visit schools to observe children’s health status and provide health services, such as immunization and nutritional supplementation. Then, the hospitals keep a record of the children’s health situations and share them with the schools. Besides, school principals mentioned the importance of principal’s strong leadership, creative vision and ability to coordinate factors that may enable schools to succeed at working with various stakeholders. Evaluation report by the government emphasized the importance of involving multiple stakeholders and appropriated community participation as one of the components in the checklist [26]. (b) Negative factor Vague role of provincial officers A provincial officer reported the problems of their vague role in the NSHP implementation. The guidelines do not indicate the role of provincial level [26]. At all administrative levels, implementers pointed out the insufficiency of follow-up and supervision, which had negatively influenced NSHP implementation. In particular, school principals needed more follow-up and supervision from provincial education officers. Contents Regarding the contents, respondents at national and school levels reported diverse health problems among children as difficulties in NSHP implementation. Respondents at all levels reported gaps between health and education sectors concerning cultural barriers with respect to sexual education. (b) Negative factor Diverse health problems among Thai children Respondents at all levels pointed out a need to address various health problems among children, such as malnutrition, obesity, food safety, disability, substance use, sexually transmitted diseases and early pregnancy. Then, school principals indicated a necessity for the government to include these emerging health problems in the NSHP and recommended timely revisions of guidelines. In addition, one national level respondent suggested that the NSHP had to cover multiple aspects of health, such as mental, social and spiritual health. Moreover, health officers recognized the importance of continuous sexual education in schools from primary to vocational. However, according to education officers, it might be difficult for Thai society to accept sexual education, including the discussion of sexual intercourse and contraception. School teachers also hesitated strongly and felt the difficulty of gaining acceptance for education about sexual issues. Context As the context element, the following three positive factors facilitated NSHP implementation, especially at the school level. (a) Positive factors Sufficient understanding and acceptance of school health concepts The NSHP concept has been well-understood and accepted among respondents at all administrative levels. Provincial officers had organized annual workshops to disseminate the concept and facilitate implementation at school level from 1999 to 2001[26]. According to respondents, NSHP goals addressed well current health problems among children. Not only government officers, but also school teachers clearly understood the aims and concepts of school health. School principals indicated that school health activities created a healthy physical and psychosocial learning environment, improved educational quality and contributed to achieving educational goals. Sharing information and collaboration among schools in a same cluster School clusters are groups composed of several schools within a same geographical location for economic, pedagogic, administrative and political purposes [27]. According to the reporting of an MOE officer, the cluster system facilitated cooperation among schools, and reduced disparities of financial and human resources. Functional fund raising activities Thai government emphasized getting support from public health officers, resource mobilization from local non-government organizations, local authority and community as strategies on implementation [26]. The implementers at each level had well mobilized financial resources. Private companies financially supported at national and provincial levels. Besides, school level received support from local government and community partners, such as temples and local economic leaders. Thus, financial support for school health activities has become customary among community individuals, institutions, and companies. In the context of limited government budgets, continuous fund raising by schools is an essential factor for sustainable NSHP implementation. Discussion Using a content analysis of document reviews and key informant interviews, this study showed that NSHP in Thailand was well-disseminated and implemented across the country and that quality improvement is needed for school health activities. We identified 10 ten key factors related to NSHP implementation that covered the all four elements of ‘triangular policy framework’: process, actors, contents and context [24]. Process In the policy implementation process, matching school health activities under the NSHP with the strategies of educational policies was key (factor for NSHP implementation) at all administrative levels. The matching helped to make school health activities part of the routine work among schoolteachers. An integration of school-based activities into the existing system was a crucial factor for success [13, 28]. Moreover, awarding system created competition and elicited interest among schoolteachers in school health activities. The awarding system had various functions, serving as a structured framework, a monitoring system, a system for recognizing achievement, and a marketing tool in the competitive school climate to help schools become HPS [29]. In Singapore, the awarding system has played a crucial role in directing schools toward holistic health promotion and encouraging the practice [9]. The awarding system might be one of the reasons for the drastic improvement in the NSHP implementation in Thailand. In addition, the guidelines were very helpful for the implementation of the NSHP. Practical guidelines were also recognized as key factors for successful implementation of HPS in Vietnam and Singapore [9, 30]. Actors Regarding the actors element, vague role clarification at the provincial level and un-institutionalized capacity-building system were factors for insufficient monitoring and inhibited quality and sustainability of implementation. These limitations caused insufficient monitoring and inhibited quality and sustainability of implementation. Promotion of monitoring and evaluation is necessary for policy implementation [31]. In addition, active supervision by local managers is crucial for stimulating the practices of front-line providers in health policy implementation [32]. Therefore, to facilitate school health practices in schools, provincial education staff must play a role as local managers. Thus, to ensure consistency and sustainability of NSHP implementation, it might be one solution to institutionalize capacity-building systems at all levels. The importance of role clarification and institutionalized capacity-building system were also reported in the WHO technical meeting on School Health in 2015 as essential factors for successful school health implementation [33]. Contents Regarding the contents element, NSHP implementation had been inhibited by diverse health problems among Thai children, in particular cultural barriers to sexual education. Sexual practices among early adolescents have become problematic in Thailand [18, 34, 35]. While sex education is crucial to health officers, teachers and education officers perceive sexual issues to be distasteful and obscene [35]. If teacher-training programs are organized in an appropriate manner within the cultural context, these programs will promote positive attitudes toward teaching about sexual issues [36]. Since health problems among Thai children are becoming diverse and complicated, the government have to revise policy contents and guidelines on time. Context Regarding the contexts element, sufficient understanding and acceptance of school health concepts, and functional fund raising activities strongly influenced NSHP implementation. Moreover, readiness of both society and schools for school health activities facilitate them. These understanding and acceptance could enable various stakeholders to participate and provide financial assistance for the activities. Moreover, established MOU facilitated collaboration among NSHP implementers. Since comprehensive school health is a broad concept with few visible short-term impacts, it is important for NSHP implementers to understand the school health concepts and share a clear long-term vision among implementers [13]. Inter-sectorial cooperation was a key to reducing obesity among schoolchildren in Thailand [37]. Previous researches reported on the importance of understanding of concepts and commitment of implementers at all levels for nationwide NSHP implementation [13, 38]. Moreover, other researches recognized teachers’ understanding of concepts and strong professional skills for school health as key factors for successful implementation [38, 39]. Besides, Thailand created positive norms on education and health promotion and has experiences of fruitful health promotion activities at the grass roots level [40, 41]. This social readiness might facilitate understanding and acceptance on school health among stakeholders. In addition, Thailand possesses an open grants system for health promotion activities at school and community [40]. This existing grants system may facilitate local initiatives for health promotion activities. As for readiness at the school level, since Thai schools had the cluster system, they could cooperate with nearby schools. Activities under the system stimulated peer monitoring among schools to improve the school management quality [42]. Under limited human and financial resources, utilizing the school cluster system is effective for human capacity building [43]. This existing educational system made minimized disparities among schools and facilitated sharing information on school health. In addition, allocation and training of school health teachers contributed to promotion and sustainability of school health activities at the school level. Moreover, strong leadership of school principals was a key for fund raising and involving multiple stakeholders. Several limitations should be taken into account to interpret these findings in this study. First, we included only governmental implementers as key informants. Responses from other stakeholders, such as members of donor agencies, private companies, local municipalities, community members and schoolchildren, might provide additional insights. Second, this study focused only on policy implementations in progress. Analysing a history of NSHP implementation might provide additional insights, especially in the context aspects. Third, we did not analyse the outcomes of the policy implementation. We need to evaluate the effect of policy implementations in the further researches, such as how much children’s health status improved after they received NSHP implementation. Fourth, this study has limitations of number of interviews and absence of documented resources for validating information from interviews. Fourth, some study results (need to clarify the role of provincial level and set up institutionalized capacity-building system) were based on one person’s report. Although recent WHO documents supported this finding, collecting further information from more diverse resources would strengthen the evidence. Therefore, collecting further information from more diverse resources would strengthen the evidence. Fifth, the data in this study were collected in 2011. Therefore, conditions on NSHP implementation today may not remain similar to those in the period of data collection. However, it was reported that multi-organization and local network involvements were important as factors for successful NSHP implementation as well as situation in 2011 [44]. Despite these limitations, this study offered four important insights for nationwide NSHP implementation. First, regarding the background context for policy implementation, all implementers should understand and accept school health concepts. Second, regarding the school-level context, school should cooperate and share information among schools and well-developed social norms on education and health promotion. Third, in the implementation process, NSHP should be matched with ongoing educational strategies. Fourth, regarding actors, government should clarify the role clarification at the provincial level and set up institutionalized capacity-building system at all level. In conclusion, the NSHP was well-disseminated and implemented at all administrative levels across four provinces in Thailand. However, the quality of school health activities was insufficient. The government should clarify the role of provincial level and set up institutionalized capacity-building system to strengthen monitoring and evaluation activities of NSHP. Funding This work was supported by the Ministry of Health, Labor and Welfare of Japan [Kosei Kagaku Research Grant, International Cooperation Research Grant 24S2, 27S1] and JSPS KAKENHI [grant no. 25282204]. The study sponsor did not have any specific role in any procedure of this study. Conflict of interest statement None declared. References 1 World Health Organization. Health promoting schools: A framework for action. WHO Western Pacific Region. 2009 [Online] Available at: http://www.wpro.who.int/health_promotion/documents/docs/HPS_framework_for_action.pdf? ua=1. Accessed: 16 February 2018. 2 Lynagh M, Schofield JM, Sanson-Fisher RW. School health promotion programs over the past decade: a review of the smoking, alcohol and solar protection literature. Health Promot Int  1997; 12: 43– 60. Google Scholar CrossRef Search ADS   3 World Health Organization. WHO's Global School Health Initiative: Health-Promoting Schools: A healthy setting for living, learning and working. 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TI - Key factors for school health policy implementation in Thailand
JO - Health Education Research
DO - 10.1093/her/cyy008
DA - 2018-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/key-factors-for-school-health-policy-implementation-in-thailand-0Zz1wtPdND
SP - 186
EP - 195
VL - 33
IS - 2
DP - DeepDyve
ER -