Report of the ‘Health in All Policies’ Focus Area Group on: EDUCATION & HEALTH ppt

Report of the ‘Health in All Policies’ Focus
Area Group on:
EDUCATION & HEALTH











2

Title: Report of the ‘Health in All Policies’ focus area group on education &
health
Date: July 2011
Authors: Noëlle Cotter (Institute of Public Health in Ireland), Owen Metcalfe
(Institute of Public Health in Ireland), David Ritchie (NHS North West Health,
UK)

This publication arises from the Crossing Bridges project (2009 12 23), which has received funding from the European
Commission, in the Framework of the Health Programme


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Contents

1. Introduction 4
1.1 Health in All Policies – intersectoral working 4
2. Executive Summary 8
3. Health and Education 9
4. Overview of Research Process 11
5. Case Studies 12
5.1 The Netherlands 12
The M@ZL project
5.2 Germany 13
HiAP overview
National Centre on Early Prevention (NZFH)
5.3 North West England 15
HiAP overview
Nursery Nutrition and Food Provision in Liverpool
Smoke and Mirror Initiative
5.4 Republic of Slovenia 18
HiAP overview
Model for Healthy Lifestyle in School
National School Nutrition Programme
5.5 Hungary 21

HiAP overview
Smoking Prevention Programme in Kindergartens & Schools
Health Promotion Pilot Project against Segregation
LOGO – Complex Youth Service System
5.6 Poland 25
HiAP overview
Joyful School ‘Radosna szkoła’
I know what I eat ‘Wiem, co jem’
5.7 Republic of Ireland 29
HiAP overview
Food Dudes: A primary education initiative to promote healthy eating
Green Schools Ireland: Focus on Active Travel
5.8 Veneto Region, Italy 32
HiAP overview
Integrated educational package on the prevention of AIDS and STIs in
secondary schools
National Project for the Promotion of Physical Activity (NPPPA)
6. What worked for HiAP, why and how? 36
7. Results 37
8. References 41
9. Acknowledgement 42

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1. Introduction

Crossing Bridges is an 18 month project that builds on work undertaken in the EC co-funded 'Closing
the Gap' (2004-2007) and 'DETERMINE' (2007-2010) projects, and will complement the 'Joint Action
on Health Inequalities' (2011-2014), to advance the implementation of Health in All Policies (HiAP)
approaches in EU Member States. It will do this by developing evidence led methods and building

capacities, as part of the overall mission to improve health equity within and between states.
Health in all Policies (HiAP) is an approach which ensures that all policy considerations, in particular
those outside of the immediate remit of health and healthcare policy, take account of the potential
to contribute to population health. A HiAP approach demonstrates an understanding that
determinants of health are principally controlled by sectors other than health. Dahlgren and
Whitehead’s diagram (figure 1 below) is frequently cited to demonstrate the multi-faceted nature of
influences on population health.

Figure 1: Dahlgren, G. Whitehead, M. (1991) Policies and strategies to promote social equity in
health, Institute of Futures Studies, Stockholm
1.1 Health in all Policies and inter-sectoral working
Recognising that ‘health’ goes beyond ‘health care’, and that health is often determined in sectors
outside of health has taken time within European policy-making but incremental progress is being
achieved, in particular with regard to the links between education and health (Grossman, 1975;
Lleras-Muney, 2006; cited in Suhrcke et al, 2011) and the work of the World Health Organisation and
the Marmot Review have made significant contributions in this regard. However, in accepting this
approach in theory, or acknowledging it as a good idea does not mean that the HiAP approach is
diligently followed. The implementation of Health Impact Assessments (HIA) in several European
jurisdictions to health-proof policies during formulation shows some improvements in this area.
However HIA is generally not a statutory requirement but health impacts are taken into
consideration within other statutory impact assessment processes, for example Strategic
Environmental Assessment (European Directive 42/EC/2001).

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The intent of ‘Crossing Bridges’ is to progress this and explore what exactly is it that ensures a HiAP
approach, or indeed what are the barriers. The method used was to explore case studies across
Europe in the areas of transport and planning, and education where health was explicitly or
implicitly addressed during the policy-making process and was an intended outcome or
unintentional by-product. Stahl et al (2006) have outlined what is needed for a HiAP approach and

‘Crossing Bridges’ intends to learn more about embedding this action.
Action and implementation of HiAP is dependent on the availability and existence of human
resources and knowledge of public health issues, health impacts and social determinants. Focus on
HiAP therefore needs to be set in a long-term and institutional context. This requires a sufficient basis
of training and research on matters of public health, health policy and determinants of health. It also
requires that action on HiAP has sufficient priority and a critical mass of support within the
government and among policy-makers, including nongovernmental organizations (NGOs). This is of
particular importance in the context of tackling more complex and long-term problems and policy-
level issues. (Stahl, T et al. (2006: 17) Health in All Policies: Prospects and potentials Ministry of Social
Affairs and Health, Finland)
‘Closing the Gap’ and ‘DETERMINE’ both worked towards increased awareness, knowledge and
willingness to implement a HiAP approach. ‘Crossing Bridges’ intends to drive this forward through
capacity building knowledge. Thus far it is known that there are six principal areas of capacity
building and awareness-raising to encourage a HiAP approach as identified in the ‘DETERMINE’
process:
 policy development
 partnership development
 skill development
 organisational development
 development of the information base
 awareness raising
In general, a partnership or inter-sectoral approach is accepted as best practice in policy-making
circles but this can be difficult to implement. Some policies merge well, for example as will be shown
in the case studies, beneficial environmental and health outcomes can be positively interwoven
when encouraging people to walk or cycle. Even in cases when policies do take a HiAP approach,
there are other unknown variables that could negatively impact, or neutralise the intended positive
effects. For example, healthy eating programmes for school children, advertising controls, food
labelling and nutritional advice, could be counteracted by actions in the home that are influenced by
policies and practices in other domains (Sihto et al, 2006). Policies can also directly clash; as
illustrated in Jousilahti’s (2006) demonstration on how the EU’s common agricultural policy could

counteract attempts to reduce cardiovascular heart disease across Europe. Moreover, particularly
given the recent economic climate, ring-fenced budgets can support silo views.
At a grassroots level, such as among the community and voluntary sector, there has been a greater
move towards inter-agency cooperation and inter-sectoral working. Himmelman (2004) developed a
matrix to demonstrate the differences between various levels of inter-sectoral working using
definitions from a healthcare setting; ranging from a more informal basis to full integration.
However, this is frequently reliant on a ‘champion’, a person who wants to drive forward multi-
sectoral and integrated working, or alternatively is reliant on a top-down instruction. Use of a
‘champion’ or a direct top-down order to implement integrated working may also be less complex to
implement in terms of direct service provision than at the policy-making level where there are more
complex competing interests; in particular ‘champions’ of other issues working in diverse directions
to HiAP.

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Box 1 Matrix* of Coalition Strategies for Working Together
Definition
Networking
Coordinating

Cooperating
Collaborating


Exchanging
information for
mutual benefit

Exchanging information for
mutual benefit, and

altering activities to
achieve a common purpose

Exchanging information for
mutual benefit, and altering
activities and sharing resources to
achieve a common purpose

Exchanging information for
mutual benefit, and altering
activities, sharing
resources, and enhancing the
capacity of another to
achieve a common purpose
Relationship
Informal
Formal
Formal
Formal
Characteristics

Minimal time
commitments,
limited levels
of trust, and no
necessity to
share turf;
information
exchange is the
primary focus

Moderate time
commitments, moderate
levels of trust, and no
necessity to share turf;
making access to services
or
resources more user-
friendly is the primary
focus
Substantial time commitments,
high levels of trust, and significant
access to each other’s turf; sharing
of
resources to achieve a common
purpose is the primary focus
Extensive time commitments, very
high levels of trust and extensive
areas of common
turf; enhancing each other’s capacity
to achieve a common purpose is the
primary focus
Resources
No mutual
sharing of
resources
necessary

No or minimal
mutual sharing
of resources

necessary

Moderate to extensive
mutual sharing of resources
and some sharing of risks,
responsibilities, and rewards
Full sharing of resources, and full
sharing of risks, responsibilities,
and rewards


Source: Himmelman (2004)
*Himmelman states that in reviewing this chart, it should be borne in mind that these definitions are developmental and, therefore, when moving to the next
strategy, the previous strategy is included within it. None is superior; rather, each may be more or less appropriate.

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In a similar vein to the Crossing Bridges project, the Public Health Agency of Canada published
Crossing Sectors – Experiences in intersectoral action, public policy and health (2008). This was
prepared in collaboration with the Health Systems Knowledge Network of the WHO’s Commission
on Social Determinants of Health and the Regional Network for Equity in Health in East and Southern
Africa (EQUINET). This, and an associated publication Health Equity through Intersectoral Action: an
Analysis of 18 Country Case Studies (2007), intended to similarly identify what ensures intersectoral
action to promote health equity through an analysis of case studies from high, middle and low
income countries. Their results are parallel to those found in this report focussed on EU member
states. There is no over-riding paradigm transferrable to each context; rather there are a series of
strategies based on the existing situation that appear to facilitate intersectoral action. These
identified strategies will be further discussed in the final section to combine the evidence for
proposals for developing HiAP.
Norway has been particularly progressive in attempting to ensure a HiAP approach and in 2009 the

World Health Organisation (WHO) published an outline for how this HiAP process was developed
(see Strand et al, 2009). What can be learned from the Norwegian experience is that the political,
policy, and problem streams merged to progress a HiAP approach. The mechanisms that appear key
and potentially universal to this positive HiAP outcome, that could be applied elsewhere are:
 Development of a strong evidence-base, coupled with clear communication of the outcome
messages.
 A willingness among the policy developers and makers to partake in this process based on
national policies of social inclusion and equity.
 Cooperation without cynicism between research, NGO and civil service actors.
 Formal structures to make the links and communicate the health inequity perspective in
seemingly unrelated policy arenas.
 Despite the creation of these new structures and ‘policy entrepreneurs’, existing
infrastructures and budgets to be used to ensure embedding of the HiAP process, rather
than as an add-on.
The common theme across these five points is the need for seamless sharing of knowledge and skills
across the policy spectrum which includes an abandonment of silos and breaking down the barriers
between esoteric knowledge. What also potentially contributed to this relatively rapid uptake of a
HiAP approach in Norway was political willingness. Although this may not be present in all countries,
this can be developed by highlighting that HiAP is a sensible approach to ensuring other key
manifesto and policy promises are fulfilled. Demonstration of financial savings that could potentially
be made by health equity is controversial; there are moral reasons for health equity and the
arguments should not be reduced to cost benefit analysis. However, in the absence of interest in
health equity and particularly in light of the current straitened times financial savings may be the
most appealing method to encourage interest.

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2. Executive Summary

The influence of education on health status has been well-documented; particularly in the context of

the social determinants of health. Educational attainment can frequently be used as a proxy for
socio-economic status which both in turn can be used to predict health outcomes. A recent WHO
systematic review (2011) also noted the influence of health on educational outcomes, however
causality cannot be assumed. In addition to the relationship being complex, it can also be difficult to
state definitively the impact or correlation of education or health interventions on each other. It can
be a challenge to measure or evaluate the long term effects of, e.g. early years interventions, and
rather measurement focuses on the more narrow immediately apparent indicators. Despite these
limitations, it is accepted that education plays a significant role in the social determinants of health
and that the relationships between health and education are inherently linked.
Eight countries/regions submitted seventeen ‘health and education’ case studies to the ‘Crossing
Bridges’ project with the intent of providing policies/projects/initiatives as examples to inform
capacity-building for a ‘health in all policies’ agenda. Central to this was the question of what made a
‘health in all policies’ approach succeed or prove challenging in an educational policy context. Case
studies were diverse; seven dealt with nutrition and/or physical exercise, five with early years
developmental health (including neglect of children and breastfeeding) and five dealt with risk
behaviours such as school drop-out, sexual activity, tobacco and other substance misuse. These
could be divided into two principal categories; encouraging healthy lifestyles and positive health
outcomes for young children, and avoiding risk behaviours that would impact on older children’s
health. These case studies are summarised in the main report, and a separate annex provides the
original case studies sources. These case studies do not claim to be representative, and identification
of case studies did not involve systematic country/region reviews but rather deferred to the local
knowledge of work group partners. A diverse and rich body of data was gathered and key points to
develop a health in all policies agenda are outlined below:
 Political expediency: getting buy-in at the highest levels of policy formation may be ideal if
it is not already present. If not present, the importance of health to multiple policy agendas
should be highlighted.
 Established regulations and relationships: Frameworks for inter-sectoral work are very
important to facilitate this process, however relationship-building within these frameworks
cannot be legislated for – this may be where higher ranking staff can play a role in ensuring
cooperation. Shared budgets and agendas facilitate flexibility and much successful inter-

sectoral collaboration. There is a need to move beyond rhetoric to systematic action.
 Communication: Learning to utilise other stakeholders’ knowledge and expertise may
require engagement on their own territory using language they are familiar with in their own
domains. The complexities of other sectors and systems must be recognised and not shied
away from. The usefulness of new technologies for information dissemination, sharing ideas
and attracting attention should not be under-estimated.
 Implementation: Implementation is needed at all levels and although an impetus may
originate from the top-down or bottom-up, engagement and buy-in at all stakeholder levels
is needed and useful for tapping in to expertise.
 Evidence and evaluation: Having an evidence-base for the policy, project or programme
assists the strength of the argument for implementation and ongoing monitoring and
evaluation not only ensures constant vigilance and a strong evidence-based, but also keeps
the project in the spotlight.
 Sustainability: Keeping the costs low, reinvention and expansion, and ensuring the least
disruption to staff assists the sustainability of programmes.

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3. Health and Education

In 2011 the WHO published a systematic literature review of the impacts of health and health
behaviours on educational outcomes in high-income countries. This review noted that much of the
literature available in this area focuses not only on developing countries, but also on the impact of
education on health. This review intended to look at evidence from developed countries as well as
the relationship from the opposite direction; if better health leads to a better education. Specifically
the authors focussed on the following:
 Does poor health during childhood or adolescence have a significant impact on educational
achievement or performance?
 Does the engagement of children and adolescents in unhealthy behaviours determine their
educational attainment and academic performance?

Based on the evidence reviewed, some of the principal findings included the following:
 Overall child health status positively affects educational performance and attainment. For
example, reviewed studies turned up evidence that good health in childhood was linked to
more years in education, that sickness significantly affected academic success and sickness
before age 21 decreased education on average by 1.4 years.
 There are negative effects on educational outcomes of smoking and poor nutrition that may
outweigh the negative effects of alcohol consumption or drug use.
 There appears to be a significant positive relationship between physical exercise and
academic performance.
 Obesity and being overweight are negatively associated with educational outcomes.
 Sleeping disorders, anxiety and depression may impact on educational outcomes.
The WHO systematic review outlines that there are significant links between education and health,
but these can often be difficult to definitively establish and causality frequently cannot be assumed.
These authors also outline elsewhere (2005) that the direction of a relationship can move in both
directions – better health can lead to better educational outcomes, but in addition better education
can lead to better health.
Given the rigorous nature of academic research and problematic research artefacts such as self-
reported health, causality and unknown and unquantifiable influences, it can be difficult to establish
clear links between health and education although it may be otherwise apparent that there is a
logical correlation. Therefore, research and advocacy is in a bind of wishing to remain loyal to a
rigorous academic process which may only be achieved by focus on variables with very clear
relationships to health while wanting to move away from these clear measurable correlations. For
example, the clearest way of showing links between health and education may be through
evaluation of an intervention and that intervention will have a clear, defined and measurable
relationship to health. However this will generally mean a focus on a lifestyle factor rather than a
more abstract policy ‘intervention’ that appears to have little in common with health policy, and in
fact may have multiple other positive impacts on health that are not apparent within the formal
educational spectrum.
In formulating the research question for ‘Crossing Bridges’ work group partners, certain factors had
to be taken into account; the resources available, as well as the necessity for a clearly formulated

question. This ensured a greater focus on policies from across Europe that had apparent links
between health and education rather than these more obtuse policies. However, work group

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partners have provided a wealth of case studies which will inform the capacity-building process.
These include:
 Nutritional programmes
 Physical exercise and developmental programmes
 Mental and physical well-being programmes
 Tobacco and alcohol control programmes

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4. Overview of Research Process

Partners were asked to submit abstracts of potential case studies for review and comment; case
studies could be amended or rejected as well as accepted. The case studies had to clearly
demonstrate a ‘health in educational policy’ measure and policies that did not work as well as those
deemed successful were welcomed. Details of the case studies are outlined below, but in sum, many
could be classified as health promotion measures that happened to occur in educational settings,
and overall the focus was on improving health outcomes for children. Once a case study was
accepted, partners were asked to arrange interviews with at least one individual involved in the case
study development/implementation and complete a reporting template (see accompanying
document Annex 1). This reporting template also included an overview of the ‘health in all policies’
specific to the partners’ countries/regions. A preliminary analysis and overview of these case studies
was presented to partners for verification and opinion. In addition, drafts of the final reports were
circulated among partners for further verification and correction.
These case studies were identified by focus area group partners with regard to their
countries/regions and therefore there was not a rigorous and uniform selection process across the

project group. However, the intent was to defer to the knowledge and expertise of the focus group
partners to identify case studies that they considered worthy of inclusion, and it must be
acknowledged that there may be many more potential examples not identified by partners.

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5. Case Studies

In total, there were 15 ‘health and education’ case studies; seven dealt with nutrition and/or
physical exercise, three case studies dealt with early years developmental health and five further
case studies dealt with risk behaviours such as school drop-out, sexual activity, tobacco and other
substance misuse. Therefore the focus fell into two areas – encouraging healthy lifestyles and
positive health outcomes for young children and avoiding risk behaviours that would impact on older
children’s health. These case studies are outlined below, alongside an overview of each
country’s/region’s experience of HiAP.
1

5.1 The Netherlands
The M@ZL project
This project developed from schools’ concerns about the growing problem of children’s absences
from school; the Netherlands has legislation with regard to non-excused absenteeism but not for
excused absenteeism which is often related to medical reasons and infrequent attendance at school
is associated with school drop-out. The M@ZL project was developed as a close partnership of youth
health care, secondary school boards and the municipal education attendance service. When a
significant number of schooldays are missed the secondary schoolchild has a compulsory
consultation with a physician and if this is not fulfilled a school attendance officer undertakes further
action. The school attendance officer provides the legal framework within which the physician can
intervene and provide any necessary additional advice to the child’s parents and school. Physicians
receive training and peer-support for these roles, and development, implementation and evaluation
was received from Maastricht and also Tilburg universities.

Developed by: Youth health care, secondary school boards, municipal education attendance
service
Context: Concern about medical absences from school and interaction with early school leaving
Conceptual approach: social determinants of health
Keys to success:
 Would not have been possible without a well organised network of social workers and
school health coordinators.
 The local health care organisation believed in the importance and efficiency of the
intervention and enabled the project leader to develop the strategy.
 Support (development, implementation, evaluation) from the social medicine field in two
universities.
 Finance was available at the beginning. However current reliance on local and school
financial resources may be a drawback for schools hoping to introduce the intervention.
 Information was made available to children and their parents.
 Training and peer support for physicians has also been key to success.
 M@ZL has been included in a national intervention database for others to follow.
 To maintain interest, short term results can be seen which can encourage staying with an
intervention beyond the availability of data on long term outcomes.
Evaluation: By two universities

1
The Netherlands Institute for Health Promotion although not an official partner in this work strand, kindly
submitted a case study however the Netherlands experience of HiAP is not available.

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5.2 Germany
HiAP overview
In Germany there is no universal strategy on Health in all Policies but many of the other German
ministries, alongside the Ministry of Health, have included health promotion and prevention into

their programmes and activities. Inter-sectoral cooperation taking health aspects into account has
gained importance recently and there are a variety of good practice examples in Germany regarding
successful inter-sectoral cooperation to include health impacts. However HiAP tools, like Health
Impact Assessment (HIA), are not regularly used and there is little explicit reference to HIA in
Germany.
2
However Germany’s Environmental Impact Assessment process (regulated under German
law since 1990) includes health impacts as part of its evaluation.
In 2005 a coalition agreement was made for the development of an early prevention system by
better interlinking health services, children and youth services and other relevant actors. In 2007,
the National Centre on Early Prevention (NZFH) was established by the Federal Ministry for Family
Affairs, Senior Citizens, Women and Youth (BMFSFJ) within the framework of the action programme
“Early Prevention and Intervention for Parents and Children and Social Warning Systems”.
“National Centre on Early Prevention (NZFH)”
This initiative is provided by the Federal Centre for Health Education in Germany (BZgA) and the
German Youth Institute (DJI) and is a nationwide programme to improve the protection of children
against neglect and/or abuse; the programme in general addresses all parents-to-be and parents
with small children but has a specific target on troubled families living in adverse social settings. The
NZFH supports interdisciplinary cooperation between health services, the Child and Youth Support
Service and other institutions like the Pregnancy and Parenting Advisory Services or women’s
support institutions. Close cooperation improves the access to families in need, the early
identification of risks and the motivation of these families to accept help. A top-down approach was
found to work best for developing networks, while implementing the initiative successfully used a
central coordinating office and binding cooperation agreements.
The NZFH has developed an information platform on early childhood intervention, transfers this
knowledge into action and informs the public. A central part of the programme is the support and
coordination of the evaluation of pilot projects in early childhood intervention.
Developed by: In 2007 the National Centre on Early Prevention (NZFH) was established by the
Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ).
Ongoing responsibility: The responsibility of the NZFH belongs to the Federal Centre for Health

Education (BZgA) which belongs to the portfolio of the Federal Ministry of Health (BMG), the
German Youth Institute (DJI), a non-university research institute that is mainly funded by the
BMFSFJ. The central office of the NZFH is situated at the Federal Centre for Health Education in
Cologne.
Context: Heightened public awareness of child abuse and neglect

2
Fehr and Mekel identify 10 approaches towards HIA in Germany within the last years:
[ accessed 4th
April 2011]

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Conceptual approach: social determinants of health
Keys to success:
 The case study is transferable; similar programmes have been initiated in other European
countries.
 Partners understood each other’s approaches and had a common framework to define
positive achievements. Partners were also willing to cooperate (binding agreements and
inter-sectoral financing mechanisms) via a transparent communication process.
 A top-down approach was successful in implementing community networks, while a central
coordinating office and public relations work also proved useful.
 Evaluation and updating of the programme as required.
 The NZFH developed a workbook for inter-sectoral cooperation of children and youth
welfare services and the health sector which proved to be a useful tool (Werkbuch
Vernetzung).
Evaluation: By external evaluators, and also some self-evaluation.

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5.3 North West England
HiAP overview
The North West of England is working towards developing sustained approaches for reducing health
inequalities and is actively engaging leaders and policy makers across the region to secure a health
and well-being component to policy development. North West England recognises the drivers
required for the implementation of HiAP and is working to create strong alliances and partnerships;
ensuring joint decision making and enabling consultative approaches to stakeholder endorsement
and advocacy. North West England has developed and co-produced with a wide range of people and
organisations across the region, a response document to the Marmot Review on Health Inequalities
in England called ‘Living Well in the North West’. As a partner in the Marmot Review the North West
has recognised that its efforts to address health inequalities need to be refocused with more
emphasis on prevention across the broader social determinants of health. ‘Living Well in the North
West’ is not a framework with solutions as these are for local partners and communities to work
through, rather it is a long term approach that promotes a way of working locally to bring about
improvements in health and wellbeing.
This includes:
 building on the strengths, assets and resilience of individuals and communities to bring
about change
 local partnership working, and community development and empowerment that devolves
power to neighbourhoods and local people to influence policies and practices
 the need to have a greater focus on the social determinants of health and on fairness and
social justice
 the focus on health as a positive outcome of wellness, not just absence of mortality, disease
or health-damaging behaviour
 the need to recognise better the casual factors of lifestyle choices (i.e. from what people do
to why they do it) and taking holistic approaches to tackle these.
HiAP is implemented, albeit to different levels across the North West with different terminology
being utilised, for example, ‘Healthy Cities’; Preston in Central Lancashire celebrated its Healthy City
status in January 2010. Preston as a spearhead local authority has experienced significant health
inequalities between the North West and the UK generally. Most of these inequalities show

Prestonians at a disadvantage on key health indicators compared to other regions of the UK. There
are also inequalities between Prestonians depending upon where they live in the city. The Healthy
Cities movement provides Preston with an impetus to systematically tackle health inequalities. The
Preston Healthy City programme links to well-being projects in terms of healthy lifestyles and
healthy urban planning, and enables the development of formal structures to allow health and well-
being to be a mainstream undertaking for all key organisations, agencies and partners.
Recent developments in Blackburn with Darwen (BwD) include ways to embed HiAP utilising the
transition of the NHS reforms as the driving force. Working and aligning public health within local
government is an option being pursued to promote a cross departmental approach. This is via a
multi-agency approach with the strategic direction being driven from the Health and Well-Being
Board via the Local Strategic Partnership.



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Nursery Nutrition and Food Provision in Liverpool
This case study developed from the Liverpool First for Health and Wellbeing Partnership belief that
there was scope to examine nursery and pre-school nutrition across Liverpool. A review to assess
and evaluate pre-school nutrition across public and private early years settings was undertaken
using a self-reported questionnaire and a full nutritional menu analysis. General findings
demonstrated that while most nurseries understood the importance of good nutrition within their
settings, many did not have adequate food policies, relevant training or know where to find current
or specific guidelines for children under five. Phase two of this project provided for training for
nursery workers to improve nutrition in their workplace settings and outcomes were evaluated. This
phase of the project was overseen by a multidisciplinary steering group, of whom the majority had a
background in health.
Initiated by: Liverpool First for Health and Well-Being Partnership
Developed by: Multidisciplinary nursery nutrition steering group, the majority of whom have a
health background – key staff in the areas of public health, nutrition, early years, environmental

health, academics from Liverpool City Council, Liverpool Primary Care Trust, Heart of Mersey,
Liverpool John Moores University and University of Liverpool.
Other engagement: by other policy areas due to the impact of the programme on their areas of
work, for example increasing the skills and knowledge of the workforce. Health sector professionals
linked with early years professionals (regulatory bodies).
Context: A need to offer support in food and nutrition to early years setting was identified in the
context of the Liverpool First for Health and Well-Being Partnership’s role in delivering the Health
and Well-Being outcomes identified in the City Vision.
Conceptual approach: Health Promotion – early years as critical for growth and development;
nutritional policy.
Keys to success:
 The training and new nutritional policies appealed to nurseries in terms of compliance with
regulation as well as attracting parents.
 Nutritional policies also appealed in terms of the evidence-based impacts on children’s
behaviour.
 Based in a wider context of addressing health inequalities which is a major feature of the
North West England policy-level plans.
 The training, evaluation and resource elements of the programme are transferable.
 Also impacted on the staff’s own nutritional intake.
Evaluation: Self reported evaluation of the impact of training and resources.






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Smoke and Mirror Initiative
Smokefree North West, a collaborative region-wide tobacco control programme, has since 2009

operated the Smoke & Mirrors project as a method of contributing to a reduction in youth smoking
uptake in the North West, on behalf of the regions 24 Directors of Public Health. Inspired by Florida’s
Truth campaign, the initiative is now linked into the EU Help campaign and has recently been
awarded the 2010 Council of Europe Pompidou Drugs Prevention Prize. Smoke and Mirrors aims to
encourage young people to ‘see through the illusion’ created by the tobacco industry in targeting
young people as potential future customers and encourages young people to take action. Young
people have a significant lead role within the project, steering strategic direction and developments,
as well as undertaking their own self directed anti-tobacco industry projects. Key outputs of the
initiative include media and campaigning actions as well as delivery of an intervention in schools and
youth work settings. A film competition and a campaign weekend for 100 young people engaged
international spokespeople in the field, respected third sector campaigners and local MPs.
Production of three winning film ideas engaged young people in the film making process and linked
to campaign actions online. Films were broadcast in cinema and virally. A Resource Pack aimed at
14-18-year olds was initially distributed to 670 Schools and 270 youth groups in the North West. The
pack has been academically evaluated and will be further rolled out in July 2011. In addition, young
people have been supported to express their views at the EU and UK Parliaments, a national tobacco
control event and through protests at Tobacco Industry AGMs. (www.seethroughtheillusion.co.uk).
Initiated by: Smokefree North West (Public Health)
Developed with: Our Life (third sector), North West Regional Youth Work Unit (education) and
young people as the target audience to include young people over age 18 as role models
Context: 24% smoking prevalence of people (age 11-17) in the North West of England which is
higher than the national average.
Conceptual approach: Health Promotion – risk behaviours
Keys to success:
 Involvement of young people in the development, delivery and evaluation.
 Collaboration – expertise was used across sectors to meet multiple needs for each sector.
 The approach was broadened to the formal education sector by tying the approach to
National Standards in Education and to the National Curriculum. The latest resource pack
also has potential to link with documents such as the UK’s policy guidance ‘Every Child
Matters’ (2002).

 Based on successful programmes in the USA.
 Evaluation by Lancaster University and feedback from this has led to the development of an
online resource for teachers and youth workers delivering the resource pack.
 Moved the anti-tobacco message away from a conventional health message and reframed
and broadened the issue.
Evaluation: As stated above by a local university, Lancaster University on the educational pack and
the anti-tobacco approach is also being independently evaluated by Liverpool John Moore
University.



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5.4 Republic of Slovenia
HiAP overview
The baseline for HiAP is given in the Slovene health care and health insurance law3 and this follows
directions given by the WHO. The general spirit of the HiAP approach is defined in article 5 “Republic
of Slovenia creates conditions for health promotion and health care by economical, ecological and
social policy measures and coordinates activities in all sectors to achieve optimal health.” Such
legislative developments in Slovenia were possible from 1992 (after separation from Yugoslavia)
because multi-sectoral work was quite well developed in the former state. In the area of health and
education there was a well-functioning multi-sectoral body to harmonise the policies in both areas.
However, there may be some discrepancies between legislative commitments and HiAP
implementation. Between 1992 and 1997 Slovenia had a Health Council which had good potential
but was wound-up before it had reached its full capabilities (human resources, specific knowledge
and multidisciplinary competences, organisational capacity).
More recently, Slovenia has been very involved with the WHO’s health promoting schools network,
and in general there is good cooperation and shared consultation with particular regard to the
domain of school nutrition. Although sectors are cooperating, the levels of cooperation are not
necessarily very demanding and often policies are developed by one lead sector and checked by the

other relevant sectors. Policy preparations do involve coordination to include adjustment during
preparations but policies are not fully integrated. A HiAP working group was established by the
National Institute of Public Health in 2011. It is expected that this project will produce an overview
of the literature and information on HiAP approaches in other countries, and an analysis of HiAP in
Slovenia is expected in 2012.
Model for Healthy Lifestyle in School
In 2008 the Ministry of Education and Sport invited the National Institute for Public Health to take
part in a project to develop model school hours in the following areas: nutrition, physical activity,
mental health, alcohol and tobacco education. These model hours were integrated into existing
subjects across primary school classes. However, it is at the teacher’s discretion to use these model
hours and therefore implementation is not uniform. The purpose of developing this programme was
to tackle the identified growing problems among Slovenian schoolchildren of overweight and
obesity, spinal deformities, psychosomatic problems and early onset of alcohol use. This programme
was developed through meetings with experts and with schools (focus groups with pupils, teachers,
parents), reviews of the curriculum, evaluation of pilot lesson plans, guidelines for implementation
and manuals for pilot lessons and physical activities. New lessons are being developed for a 2011
pilot, and for eventual roll-out to other Slovenian primary and secondary schools.
Initiated by: Ministry of Education and Sport
Developed by: Health and education sector experts; National Institute of Public Health (NIPH),
teachers from 4 health promoting schools and external experts in the Faculty of Sport, the National
Education Institute of the Republic of Slovenia.
Context: Health has been increasingly integrated into the education system since the active
involvement of Slovenia in the health-promoting schools network. A joint cooperation agreement on

3
Official Gazette of RS, 9/92, with amendments


19

children and adolescent health was signed by the National Institute of Public Health, Ministers for
Health, Education and Sport, and Labour, Family and Social Affairs in 2007. But it was not until 2008
that the Ministry of Education and Sport invited the NIPH to be part of an ESS call to develop this
programme. In addition, research data had demonstrated growing problems of overweight and
obesity, spinal deformities, psychosomatic problems, early onset of alcohol use among Slovenian
young people.
Conceptual approach: Health promotion
Keys to success:
 Political will and support.
 Began with the needs of the children and teachers.
 Embedded in the curriculum.
 Sustainability – new pilot lessons have been developed and rolled-out for 2011 and in
November 2011 there will be a conference on children and adolescent health in Slovenia
and NIPH intend to use this opportunity to strengthen inter sectoral cooperation in this
regard. However, a drawback has been the voluntary nature of implementation.
 Widespread support among the media, public, educators and state officials.
 Success enhanced by the cooperation between the schools and health experts (however a
barrier to success was the lack of resources made available by decision-makers).
Evaluation: Questionnaires and discussions with pupils and teachers at the pilot stage, and again at
the end of the pilot phase with teachers and the NIPH.
National School Nutrition Programme
Slovenian primary schools provide food during the school day, and in 2008 this was rolled out to
secondary schools to include a subsidised meal per day. Additional subsidies are also available for
children who would otherwise not be able to afford the subsidised food and vending machines in
schools have been banned.
This process began with a policy 2005-2010; Resolution on Food and Nutrition. New guidelines for
healthy nutrition in schools were launched in 2005 by the Ministry for Health and harmonised with
the Ministry for Education with the main objective of provide support to schools in the area of
nutrition. The issue of school meals became a political issue in the 2008 elections, and this policy
was developed against the backdrop of changing working hours in line with European hours and high

levels of female involvement in the labour force. Changing working hours and the unavailability of
women to prepare food for children has encouraged this policy, and while there has been criticism
of the implementation of the standards, these are currently being addressed and evaluations have
demonstrated consistent improvements.
Developed by: Ministry of Education with strong consultation and support from the Ministry of
Health.
Context: Primary school meals have been available since the 1960s, and there was mounting
pressure to extend this since 2000, and it became an election issue in 2008. Secondary school
nutrition was defined as an important goal within the Slovene Food and Nutrition Action Plan 2005-
2010.

20

In addition, Slovenian working hours have become increasingly harmonised with the rest of Europe,
and with a very high percentage of women in the workforce the typical providers of meals are not
available at eating times as they would have been two decades ago (6/7am-2/3pm).
Conceptual approach: Health promotion
Keys to success:
 Timing of the NIPH in publicising this issue during a pre-election period.
 Healthier nutritional habits and status of children and better school performance – the
drawbacks are fewer meals eaten together as a family and children are not as exposed to
cooking.
 A common understanding of the problems, awareness and enthusiasm.
 Considerable support was available to schools where implementation was very difficult.
 Nutritional guidelines for schools were already available since 2005.
 The Ministry of Education were courageous in following the advice of the health promotion
sector in banning vending machines in schools. The advice of the health promotion sector
was strongly supported by WHO recommendations on marketing food to children.
 The strength of the evidence and advice of experts – and the willingness of the Ministry of
Education to take these on board.

Evaluation: The NIPH and nine regional public health institutes regularly monitor the quality and
organisation of school meals and annual reports are produced. Self-evaluation tools are also
available for school meal providers to use.


21

5.5 Hungary
HiAP overview
In Hungary HiAP has not been fully implemented and inter-sectoral cooperation needs
improvement. However, since the new government’s election (May 2010) steps were taken to
increase inter-sectoral cooperation; the Ministry of National Resources was established in 2010 by
merging the portfolios of sport, education, culture, social affairs and health, and in 2011 government
offices at county level were formed. These offices are local public administration bodies, consisting
of administrative departments of different sectors. Former bodies of the National Public Health
Service operate in these offices within the Public Health Administrative Departments. The
government offices are legally and financially supervised by the Ministry of Public Administration
and Justice, and the Public Health Administrative Departments are under the professional leadership
of the Office of the Chief Medical Officer. These structures (ministry, government offices) provide
good prerequisites for inter-sectoral cooperation and a health in all policies approach in theory, but
it is not yet fully implemented in practice. However, good examples of implementing a HiAP
approach can be found at local level, for example in city health plans and health promoting
workplaces.
The Public Health Programme (2003-2013) has inter-sectoral cooperation as a core principle but
financial resources for implementation were scarce and the programme needs updating and
rethinking. In June 2011, the government adopted the “Semmelweis Plan” for health care reform.
With regard public health it undertakes to develop a new public health action plan which reflects a
paradigm change and reacts to identified problems. The action plan aims to renew the public health
system, to provide sustainable financial resources and to involve the whole population in public
health activities. It necessitates intersectoral cooperation to tackle health inequity and it explicitly

mentions HiAP as an important tool for this.
Health Impact Assessments, as a way of implementing HiAP, are not common practice. However, the
current Hungarian legal system provides the necessary prerequisites for HIA (for example, calls for
compulsory impact assessment of draft legislative provisions and there is an ongoing practice of
Environmental Impact Assessment).
Development plans for the EU Structural Funds also build a good platform for inter-sector
cooperation. Measures on health are mainly integrated to the Social Renewal Operational
Programme. Most of the tenders are focused on the different settings in health promotion, like
schools, workplaces and local governments, with special focus on deprived areas and socially
excluded populations.
Smoking Prevention Programme in Kindergartens and Schools
This programme developed from the evidence that basic behaviour patterns regarding smoking are
imprinted in early life. Experts at the Hungarian Focal Point for Tobacco Control developed an
effective kindergarten (pre-school environment) and school smoking prevention programme to
influence children’s current and future health behaviours. The aim of the kindergarten and school
smoking prevention programme is to generate long-term changes in the attitude towards, and
knowledge about smoking, to develop smoke-free lifestyles, and skills to reduce exposure to passive
smoking. Several age-specific, entertaining tools and methods of the kindergarten and school
programme promote the implementation by teachers, and make the learning process of the
programme exciting and interesting for children. The program is cost effective and innovative owing

22

to many available and downloadable tools on the registration website and homepage of the Focal
Point.
EU and WHO principles were considered in developing this programme which was undertaken by
health promotion professionals. Impact assessments have been undertaken demonstrating
effectiveness in attitude changes, knowledge and smoking and passive smoking control.
Developed by: Focal Point for Tobacco Control in the National Institute for Health Development.
This comprised many professionals with backgrounds in education, social and health care, public

health.
Context: High rates of smoking in Hungary (30,000 deaths from smoking-related causes each year
and Hungary has the highest prevalence of lung cancer in the world), and in 1999 the Office of
National Public Health and the Medical Officer Service of Budapest found high rates of passive
smoking among pre-school age children.
Conceptual approach: Health Promotion
Keys to success:
 Use of international and national literature and evidence base, and WHO and EU principles.
 All participants’ agendas are addressed.
 Good relationships between the different sectors.
 Recognition of the need to engage with other sectors and utilising each other’s expertise.
 Effective communication between individuals and groups.
 The programme is available free of charge.
 It can be embedded in the curriculum and the intent is not to disturb as it is not part of the
national core curriculum.
Evaluation: In one of the educational packages teachers could check the success of the information
provision and corrections can be made, focus groups have also taken place in 2009. In addition, the
programme has been monitored since inception and a larger assessment was recently undertaken
with the support of the WHO Regional Office for Europe.
Health Promotion Pilot Project against Segregation
This pilot project was developed by the Hungarian National Institute for Health Development at the
request of the Ministry of Health, in cooperation with teachers, the Educational Counselling Service,
the Budapest Hydrotherapy Gymnastics Foundation and the National Association of Professional
Roma People. It was developed to target disadvantaged children in the 8th district of Budapest to
include Roma children against the policy context of each ministry preparing the ‘Roma Decade
Programme’. The project has run for 4 years in 12 kindergarten groups and 5 school groups, and its
content has been continuously broadened over the years. The target group of 5-9 years old children
with immature senso-motor skills have been improved by senso-motor development training to
enable a better start at school. Results in the past year have shown that children taking part in the
training develop at a faster rate than those developing spontaneously. According to general trends,

children with weaker skills in lower socio-economic groups have little chance to catch up with those
of better skills. With the help of the training, these general trends can be altered and they are
provided with equal chances for mainstreaming. The following health impacts are mentioned in
supporting documents: improving health literacy, decreasing prevalence of depression and
unhealthy/destructive lifestyles.

23

Initiated by: Ministry of Health
Developed by: National Institute for Health Development with local teachers, Educational
Counselling Service, Budapest Hydrotherapy Rehabilitation Gymnastics Foundation, National
Association of Professional Roma People.
Context: A Roma Decade Programme was underway, and each Ministry had to submit
projects/programmes. The Ministry of Health wanted to develop a project to address Roma health,
but this project went beyond this group to the wider group of disadvantaged children in a Budapest
district.
Conceptual approach: Determinants of Health (targeted disadvantaged children)
Keys to success:
 Decisions were taken at the lowest level in the hierarchy as teachers knew what was most
needed.
 After the pilot phase and when further expansion is desired, local government can take over
the project leading to the institutionalising of the intervention.
 Enthusiasm – a good collaborative climate was established:
 Inter sectoral cooperation, as well as good communication with other stakeholders.
 Informal cooperation was integral, formal frameworks of inter sectoral cooperation were
not sufficient. An embedded HiAP approach could possibly have worked better to assist buy-
in from funding bodies.
 Teacher’s willingness to take on additional hours to a disproportionate level to the
remuneration. Teacher training for this programme was accredited which was very
important.

Evaluation: The National Institute for Health Development used a monitoring protocol for health
promotion initiatives during the implementation phase. Children’s development was monitored and
recorded on a monthly basis. There was also a control group, and assessments of this group and the
intervention group were undertaken by an independent group. Teachers have case consultations on
a monthly basis (during the planning phase they were consulted with a RAR technique – rapid
assessment and response focus group method).
In addition, teachers examine children twice a year to monitor any further developments and more
recently peer evaluation is taking place.
LOGO – Complex Youth Service System
Research was conducted in Hungary’s Vas County in 1999 to include an analysis of the health
situation of young people. Based on this research and in cooperation with local governments (city of
Szombathely and county of Vas), NGOs, youth institutions and student governments, a county level
Youth Project Plan was developed in 2000 to include LOGO. The innovative “MMIK LOGO Youth
Service” (LOGO) was established in Szombathely4 in 2002 as a part of the Cultural and Youth Centre
of Vas County (MMIK). LOGO is a human service centre providing primary care-like low-threshold
services for young people aged 12-30. It aims to enable the members of this age group to:
 get to know their rights, obligations and the different institution systems
 take advantage of possibilities and live a healthy and full life

4
county town of Vas county in the North-Western part of Hungary

24

 become more mature in their personality
 use and improve their skills, to successfully meet the challenges of their age and life
situations
 consciously tackle their possible disadvantages
Activities include: providing information, counselling and a community space; forming a county
network; doing out-reach youth work; organizing events; implementing international youth projects

and transnational exchanges. There is an emphasis on establishing and improving the health literacy
of young people with interactive methods, in cooperation with health promotion experts.
Initiated by: Cultural and Youth Centre of Vas County (MMIK)
Developed by: local government (city and county), NGOs, youth institutions, student governments,
regional public health service, cultural experts, mental health expert, sport expert, IT expert.
Context: Since the 1990s and up to 2000 there had been a youth information and counselling office
in MMIK. This service had experienced major cutbacks. In 1999 youth research in Vas County
demonstrated a need for young people to have a local youth service system in their area and the
2000 Youth Project Plan for Vas County stated that local youth services should be supported.
Conceptual approach: Health promotion and social determinants
Keys to success:
 Recognition of the importance of a service such as this, based on the existence and
experiences of a similar service that had been cutback for financial reasons. Other evidence
was used from the European Youth Information Charter and the professional and ethical
code of the Hungarian Association of Youth Information and Counselling Offices.
 A field trip to Austria also assisted in development of this programme.
 All stakeholders were identified and involved before any decisions were taken. In addition
the target group were also involved in the development.
 Excellent communication took place with monthly meetings during the development.
 An informal network in Vas County between similar youth services provided a good platform
to share the LOGO experiences.
 It was unique, but a very successful cooperation between the local and county governments
despite political differences.
 All agencies had their own agendas sufficiently addressed and hence a collaborative
environment was feasible. The inter-sectoral collaboration depended on individual
personalities and highly committed persons, when staff moved jobs the replacement person
was not always as enthusiastic. However, tools for inter sectoral collaboration were deemed
in this research as potentially being too artificial.
Recognition: Vas County local government declared ‘LOGO-Mobil’ a trademark and publicised it
throughout Hungary. The Ministry responsible for Youth Affairs declared LOGO a model project.

Evaluation: Health indicators are not monitored as there are insufficient human resources for such
an endeavour and it may not be practical as many young people migrate for work/education upon
adulthood. However, there are regular audits of different applications within the overall programme.
The Hungarian Association of Youth Information and Counselling Offices analysed LOGO and have
made it an associated partner of their alliance.

25

5.6 Poland
HiAP overview
In March 2002 the Council of Ministers passed Resolution No. 49 requiring every kind of legislation
(e.g. new acts, changes in the law) to be assessed in terms of the potential impact on the
population’s health. This is done through cross-ministerial discussions as well as consultations with
relevant research bodies. This includes policies in the areas of: social policy (anti-poverty
programmes, social inclusion, social security), food safety (production, processing, sale), agriculture
(production, health of farmers), workplace safety (detailed regulations in labour law), emergency
planning (emergency procedures exist at every administrative level), regulation of tobacco and
alcohol use (anti-tobacco law, law on education in sobriety and prevention of alcoholism),
environmental policies (Environmental Protection Law), transport and road safety. The National
Health Programme (NHP) was first introduced in 1990 on the basis of the policy Health for All by the
Year 2000. The current NHP (2007-2015) provides the Ministry of Health with the potential to
influence activities in the area of health in other sectors and aims to integrate health policies across
all sectors and there are many representatives involved.5 The NHP is based on the framework of the
World Health Declaration, Health for All in 21st Century Strategy, the new public health strategy, and
the draft Decision of the European Parliament and the Council establishing a second Programme of
Community Action in the field of Public Health.
The NHP is an integral part of Healthcare Development Strategy for Poland 2007-2013. Its main
objective is
“…improving health and related quality of life of the population, and reducing health inequalities
achieved through: promoting a healthy lifestyle, creating a work and learning environment

conducive for health, activating local government bodies and non governmental organizations to
take joint actions for health”.
NHP has eight strategic health-objectives (e.g. reducing the incidence of principal national health
problems), six operational objectives concerning risk factors and actions for health promotion, five
operational objectives concerning selected population groups (e.g. children, elderly, disabled) and
four essential activities to be taken by health protection authorities and local government bodies.
NHP specifies expected outcomes and health benefits to be achieved by 2015 and which are
monitored by the National Institute of Public Health – National Institute of Hygiene.
At the regional (voivodeships) and local (poviats) level there are many health committees appointed
that cooperate with many local institutions (e.g. schools, NGOs) and leaders for the health
improvement of residents.
Poland also plays active role in international initiatives, for example the European Healthy Cities
Networks.


5
Chancellery of the Prime Minister, Ministries of: Agriculture and Rural Development, Construction, Culture
and National Heritage, Economy, Finance, Interior and Administration, Justice, Labour and Social Policy,
Marine Economy, National Defence, National Education, Regional Development, Science and Higher Education,
Sport, Environment, Transport; National Health Fund, Agricultural Social Insurance Fund, Association of Polish
Cities, Association of Polish Counties, Central Statistical Office, Union of Polish Metropolises, Union of Polish
Towns, medical self regulatory bodies, selected representatives of NGO's, Union of Rural Communes of the
Republic of Poland, Union of the Voivodeships of the Republic of Poland.