Health Promotion International Advance Access published September 10, 2014 Health Promotion International doi:10.1093/heapro/dau076

# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]

Effects of the School for Health network on students’ behaviour in Asturias (Spain) ´ ZQUEZ* JOSE GARCI´A-VA Regional Ministry of Heath of Asturias, C/Ciriaco Miguel Vigil, Oviedo 9-33006, Spain *Corresponding author. E-mail: [email protected]

From 1995, Asturias participates in the European Network of Schools for Health (SHE); in 2010, the schools in net were 44 (11 of secondary school). This study evaluates the effect of SHE in secondary school students’ behaviour. A quasi-experimental study was conducted with four public SHE and four non-SHE-schools; the study population consisted of the first- and fourth-year students. By questionnaire, data on socio-demographics, the school environment, well-being and behaviours were collected. In the intervention group (the SHE-schools), the percentage of students who declared that their school engaged in health activities was significantly higher. Among the first-year students, the percentages of children having breakfast daily, occasionally eating pastries and occasional consumption of soft drinks were significantly higher in the control group; among the fourth-year students, the percentages of children

reporting high school satisfaction, good relations with teachers, good academic performance, no alcohol use, never having been drunk and collaboration in housework were significantly higher in the intervention group. Significant gender differences were observed among the first-year students in both groups with boys consuming more hours of electronic entertainment; among the fourth-year students, the perception of school performance was significantly better for girls, while weekly physical activity, daily breakfast and high self-esteem were more prevalent among the boys. The results suggest a positive effect of the SHE programme, because differences among the first-year students favouring the control group were not present among the fourth-year students, while the intervention group showed significantly better results in 6 of 25 compared outcome variables.

Key words: health promoting school; adolescent; health behaviour

INTRODUCTION Schools for Health (SHE) is a concept to incorporate health promotion in daily school life by developing personal capacities and structures supportive to healthy decision-making (WHO, 1986; Garcı´a, 1998; Gavidia, 2001). It is based on the principles of democracy, equality, action competence, safe and favourable school environment, curriculums based on health education and promotion, teaching staff training, continuous assessment, collaboration with other agents, involvement of mothers, fathers and community and sustainable development (WHO, 1997). A European Network of SHE has been created, by the WHO and the European Commission, to

incorporate the Health Education and Promotion (HEP) at the school, from the democratic management of the centre to the care for the physical environment and the interpersonal relationships (Barnekow and Rivett, 2000). This proposal is based on varied research which suggests that, if properly implemented, SHE can make adolescents feel healthier, have higher self-esteem, adopt healthier behaviours and that there is improvement to their health (Lister-Sharp et al., 1999; St Leger, 1999; UIPES, 2003; Mukoma and Flisher, 2004; Stewart-Brown, 2006). Asturias is a region in northern Spain, with a million people, mostly public education system with 450 schools and 80 000 primary and secondary students. This region has participated in Page 1 of 9

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SUMMARY

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METHODS A quasi-experimental study was carried out with secondary school students from state SHE (intervention group) and from those who were neither members of the net nor had a HEP project subsidized by the Regional Ministry of Education or Health (control group). The collection of information was conducted through a self-administered questionnaire including questions validated in the previous research and which was filled out by the students (INE, 2008; Margolles and Donate, 2009, 2010). Two levels were prioritized: first and fourth year of secondary education (Spanish ESO). The first-year students were selected because it was assumed that SHE had no effect or a low effect on their behaviours, and the fourth-year students were selected because they had spent 4 years in the centre and if there were an effect, it would be more intense at this level. Based on this hypothesis, the following students were excluded: in the first year those students repeating a course (more

than one course in the school) and in the fourth year those who had not actually studied for the whole four years in the school. The surveys were delivered to the students by an external visitor who collected them in May 2011. There was only one time point of data collection, when the intervention and control groups were compared, simulating a longitudinal study by contrasting first- and fourth-year students. We assumed the differences we observed among the fourth-year students to reflect an effect of the programme that was not present 4 years earlier. However, due to the cross-sectional design of the study it was not possible to check for potential differences between the compared groups of the fourth-year students back at baseline. The sample size was determined for a confidence interval (CI) of 95% and an unknown estimated prevalence of 50%. Based on these data, the required number of centres to reach the designed sample size was selected from the target population. Subsequently, of the eight selected schools, four (which had received the intervention) were assigned to the intervention group, while the other four were assigned to the control group. The choice of SHE was not at random because those with the higher scores during the incorporation process to the net were chosen (Garcia-Va´zquez et al., 2009a,b). We used best practice models in Asturias as benchmark for comparison, because in case there was an effect, it would be more intense and therefore detectable in this situation. For each of these schools, a control in the same educative area was randomly selected. In total, eight state schools of secondary education participated (out of 70 in Asturias). In the intervention group, 285 students from the first year and 274 from the fourth-year answered the survey; in the control group, 258 from the first year and 273 from the fourth year. The response rate was 100% in all the groups, and the absentee rate was lower than 3%. For the purposes of this study, the variables were classified into five categories: socio-demographic (age, gender and nationality), family, school, behaviour and emotional well-being. The family items were family members they live with (a nominal and dichotomous variable [YES/NO] for mother, father, brothers/sisters, grandfathers/ grandmothers, uncles/aunts and others). A valuation of the family relationship and the economic situation of the family were also obtained. In relation to the school, the questions were satisfaction with the centre, relationship with

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SHE since 1995, when two centres joined the network; in 2010, the number of schools reached 44 (10% of the schools in this region). In order to join the network, these centres had a HEP project subsidized by the Regional Ministry of Education and Health, which made an annual call for this purpose. They also had to pass an evaluation process which included a visit of external personnel to observe the school and its surroundings, a revision of school policy documents and meetings with the management team, the teaching staff and the students, and to assess the compliance with the network criteria (Garcia-Va´zquez et al., 2009a,b). Different process indicators were analyzed, including school health policy, involvement of the management team, teaching staff participation, student participation, implementation of curricular and extracurricular activities, as well as environment and community collaboration. As a result, centres that exceeded a score of 5 (out of 8 possible points) became part of the network and received the School for Health distinction (Garcia-Va´zquez et al., 2009a,b). Despite having this evaluation of the process, the effect on the students has not been assessed. Under these circumstances, the following study has been proposed in order to evaluate the effect of SHE on the health-related behaviours of secondary school students in Asturias.

SHE on students’ behaviour in Asturias

RESULTS Students from the first year Socio-demographic variables The mean age was 12.5 years (SD 0.06) in both groups and the proportion of boys was slightly higher (52.3% in intervention and 51.9% in

control) (Table 1). In relation to the nationality, almost all the students were Spanish (95.1% in intervention and 92.6% in control). Family Almost all the students answered that their relationships were good/very good and .70% in both groups assessed the economic situation of their family as positive. The family structures were also very similar: almost all the students live with their mother, a slightly lower percentage with the father, approximately two-thirds with brothers and/or sisters and in minority percentages with grandparents, other couples of the mother or the father and uncles/ aunts. There were no significant differences between the intervention and control group concerning demographic and family variables. School Approximately 40% of the adolescents studied in a primary school with the HEP project. Regarding their current centre, the perception was significantly different: 76.1% in the intervention group were aware that their school conducted activities to improve health compared with 51.6% in the control group. The differences between the rest of the school variables were not significant. Behaviours Both groups showed similar behaviours in relation to their daily tooth brushing (.90%), weekly physical activity (approximately two-thirds), have never been drunk (90%), no tobacco consumption, no alcohol consumption and no hashish/ marijuana consumption (almost all), always use safety belt (90%) and weekly collaboration in household chores (close to 90%). There were significant differences in three variables showing better results in the control group: daily breakfast, occasional consumption of pastries and occasional consumption of soft drinks. There were two more differences without statistical significance: the daily consumption of vegetables was higher in the control group and fruits in the intervention group. There were no differences in the sleep time [8.7 h in the intervention group (SD 1.19) versus 8.6 in the control group (SD 1.09)] and the electronic entertainment time [4.4 (SD 2.72) and 4.1 (SD 2.46)].

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teaching staff and schoolmates and perception of school performance. It was also asked whether HEP activities were developed in their centres [YES/NO] and the name of the centre in which they studied during primary education which was contrasted with the list of centres with HEP projects to obtain the variable Primary Education Centre with HEP [YES/NO]. All these items were designed in order to compare the groups and control potential biases that could have an influence in the behaviour variables, which were tooth brushing, physical activity in their leisure time, consumption of fruit, vegetables, pastries, soft drinks, tobacco, alcohol and marijuana, frequency of drunkenness, collaboration on household tasks and use of safety belts in vehicles. In all of them, an ordinal scale of frequency was used. Numerical information was obtained on the number of daily hours of sleep (including a nap) and the number of hours spent on electronic entertainment (television, Internet and video games). Students of the fourth year were also asked about ever having boyfriends/girlfriends, sexual intercourse with penetration, condom use for the first time, condom use for recent sexual intercourse and intention to use condom for the first time (for those who had not had sexual intercourse with penetration). All these items were nominal and dichotomous [YES/NO]. Finally, for both first- and fourth-year students, the following variables related to emotional wellbeing were included: self-perception of health status, level of happiness and personal selfsatisfaction (self-esteem). Both for these items and others not listed above, an ordinal scale of valuation was used. Data analysis was performed using SPSS 15.0 software. The means were obtained for the continuous variables and the percentages for the rest of variables and were broken down by gender, year and group (intervention and control). In order to contrast the differences, the interval difference at 95% was used.

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Table 1: Variables for the students from the first year of secondary school (Spanish ESO) for the intervention and control groups (in number and percentage) SHE

Well-being The assessment of the students’ health status, their level of happiness and self-esteem was similar in both groups, with around 90%. Gender differences A higher level of satisfaction with the school, the schoolmates and the teaching staff was detected in the girls, as well as in their perception of the school performance, but without significant differences. In the remaining variables, the differences were small, except for the practice of weekly physical activity, which was higher in the boys of both groups (79.9 versus 50.3% in intervention and 75.9 versus 59.1% in control) although without statistical significance.

Differences (95% CI)

n

%

n

%

259 206 274 229 199 39 8

90.9 72.3 96.1 80.4 69.8 13.7 2.8

238 182 246 204 171 27 9

92.2 70.5 95.3 79.1 66.3 10.5 3.5

120 217 239 258 217 173

42.1 76.1 83.9 90.5 76.1 60.7

105 133 206 227 178 156

40.7 51.6 79.8 88.0 69.0 60.5

265 186 210 126 30 169 120 270 232 243 274 244 256

93.0 65.3 73.7 44.2 10.5 59.3 42.1 94.7 81.4 85.3 96.1 85.6 89.8

237 178 211 99 44 184 146 249 222 232 249 223 223

91.9 69.0 81.8 38.4 17.1 71.3 56.6 96.5 86.0 89.9 96.5 86.4 86.4

253 260 244

88.8 91.2 85.6

235 238 234

91.1 92.2 90.7

24.5 (16.9 to 32.2)

28.1 (215.0 to 21.1) 212.0 (219.8 to 24.0) 214.5 (222.6 to 26.1)

Students from the fourth year Socio-demographic variables The mean age was 15.8 years (SD 0.78) in both groups and the proportion of girls was slightly higher in the intervention group (54.4%, compared with 52% in the control group) (Table 2). Concerning nationality, almost all the students were Spanish (94.5% in intervention and 90.8% in control) and the rest belonged to Europe, Latin America and Africa, in similar percentages. Family The family situation was similar in both groups, with good/very good relationships (.90%), good/very good economic situation (.60%) and

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Family State that family relationships are good/very good State that family economy is good/very good Live with mother Live with father Live with brothers/sisters Live with grandfathers/grandmothers Live with mother’s/father’s partner School Studied in a primary education centre with HEP project State that their current centres develop health activities Feel very/quite satisfied with their current centre Feel good/very good with their schoolmates State that the relationship with the teaching staff is good Consider that their school performance is good Behaviours Brush their teeth once or more times a day Perform physical activity several times a week Have breakfast everyday Eat fruits everyday Eat vegetables everyday Eat pastries two or less days a week Have soft drinks two or less days a week Do not smoke tobacco Do not drink alcohol Have never been drunk Do not consume hashish/marijuana Always use safety belt Collaborate in household chores weekly Well-being Consider that their health is good/very good In general, consider themselves as quite/very happy Feel good with themselves

Control group

SHE on students’ behaviour in Asturias

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Table 2: Variables for the students from the fourth year of secondary school (Spanish ESO) for the intervention and control groups (in number and percentage) SHE

Differences (95% CI)

n

%

n

%

253 177 262 220 164 48 11

92.3 64.6 95.6 80.3 59.9 17.5 4.0

249 167 266 227 162 18 11

91.2 61.2 97.4 83.2 59.3 6.6 4.0

65 125 191 265 203 147

23.7 45.6 69.7 96.7 74.1 53.7

61 70 160 259 180 123

22.3 25.6 58.6 94.9 65.9 45.1

259 153 173 32 123 37 169 140 213 84 112 236 241 233 201 93 88 74 162

94.5 55.8 63.1 11.7 44.9 13.5 61.7 51.1 77.7 30.7 40.9 86.1 88.0 85.0 73.4 33.9 94.6 79.6 90.0

258 169 179 21 106 25 162 140 227 62 89 223 243 206 206 96 84 75 165

94.5 61.9 65.6 7.7 38.8 9.2 59.3 51.3 83.2 22.7 32.6 81.7 89.0 75.5 75.5 35.2 87.5 78.1 93.2

233 238 247

85.0 86.9 90.1

231 231 230

84.6 84.6 84.2

20.0 (12.0–27.6) 11.1 (3.1–18.9) 8.2 (0.4–15.7) 8.6 (0.2–16.8)

8.0 (5.3–15.3) 8.3 (2.0–16.2) 9.5 (2.9–16.2)

with a majority family structure of mother, father and brothers/sisters, and in minority percentages with grandparents and other couple of the mother or the father.

valuation of the satisfaction with the centre, the teaching staff and the perception of their school performance.

School More than 20% of the students from both groups study in a primary school with the HEP project. In relation to their current school, there were significant differences in the perception of activities to improve health: 45.6% intervention versus 25.6% control. The percentage of the intervention group was also significantly higher in their

Behaviours They were similar in daily tooth brushing (94%), daily breakfast, daily consumption of vegetables, occasional consumption of pastries and soft drinks, tobacco consumption (70% had never consumed), hashish/marijuana consumption (.80% had never consumed) and regular usage of the safety belt (almost 90%).

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Family State that family relationships are good/very good State that family economy is good/very good Live with mother Live with father Live with brothers/sisters Live with grandfathers/grandmothers Live with mother’s/father’s partner School Studied in a primary education centre with HEP project State that their current centres develop health activities Feel very/quite satisfied with their current centre Feel good/very good with their schoolmates State that the relationship with the teaching staff is good Consider that their school performance is good Behaviours Brush their teeth once or more times a day Perform physical activity several times a week Have breakfast everyday Have breakfast 5– 6 days a week Eat fruits everyday Eat vegetables everyday Eat pastries two or less days a week Have soft drinks two or less days a week Do not smoke tobacco Do not drink alcohol Have never been drunk Do not consume hashish/marijuana Always use safety belt Collaborate in household chores weekly Have ever had boyfriend/girlfriend Have ever had intercourse with penetration Used condom for the first intercourse Used condom for recent intercourse Intend to use condom the first time (in no sexual intercourse) Well-being Consider that their health is good/very good In general, consider themselves as quite/very happy Feel good with themselves

Control group

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Well-being The assessment of the students’ health status was mostly good/very good in both groups, also the feeling of happiness, and the self-esteem was slightly higher in the intervention group (90.1% feel good about themselves versus 84.2%). Gender differences There were significant differences in the perception of school performance as good/very good, higher in boys (44.8% girls versus 61.1% boys in intervention; and 36.6 versus 52.8% in control); weekly physical activity, which was double in boys (76.0% boys versus 38.9% girls in intervention; and 82.4% boys versus 42.9% girls in control); daily breakfast, higher in boys (69.6% boys versus 57.7% girls in intervention; 71.8% boys versus 59.9% girls in control). In relation to the well-being, the boys reported feeling good about themselves more than girls, with statistical significance in both groups: 96.0 boys versus 84.6% girls in intervention and 90.1 boys versus 79.6% girls in control; the perception of their health status as good/very good was also higher in boys, but only significantly in intervention (90.4 boys versus 80.5% girls). There were other non-significant differences between gender groups, with higher percentages of girls who performed household chores, had had intercourse with penetration and greater intention to use condom for the first time.

DISCUSSION This work intended to measure the effect of studying at a SHE on the students’ behaviour. Because there is not much research in Spain (Davo´ et al., 2008) and taking into account the limitations of this study, which are mentioned later, it is necessary to be prudent about the following conclusions. The study had a high turnout, with very high response rates, which are probably related to the way the information was collected. The absentee rates were very low, and the socio-demographic and family variables were similar. Therefore, the groups were considered as comparable. Regarding the incorporation of the HEP in the study schools, it is higher in the intervention group, according to students’ perception. This finding is probably an evidence that the process to measure the HEP incorporation in the school in Asturias (Garcia-Va´zquez et al., 2009a,b), although it can be improved, it is valid because students’ answers consistently support this conclusion. Beyond this result, both groups perceive the work in HEP and the percentage of students who studied in a primary school with HEP project doubles in the first year of secondary school. This is a proof of the intense work carried out in Asturias for two decades of collaboration between the Regional Ministries of Education and Health. Probably, the most important action during this collaboration was the annual call to subsidize schools with the HEP project, which started with 13 centres in 1992 and reached 243 in 2010, more than 50% of the schools in Asturias. Despite this good result, government authorities suppressed this action from 2011. In relation to the rest of the results of this study, in the first year of secondary school, a significant difference is observed in favour of the control group for three of the eating behaviours included in the survey. This topic is incorporated in primary education, both in centres with HEP project and without, which may explain this difference. However, these behaviours are not maintained in the fourth year, where others arise also with statistical significance, but in this case in favour of the intervention group: no alcohol consumption, have never been drunk and weekly collaboration in household chores. Therefore, it could be interpreted that studying in a SHE may have some effect on the students’ behaviour because the differences in the first year in favour of the control disappear in the

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There were significant differences favouring the intervention group in three behaviours: have never drunk alcohol (30.7 versus 22.7%), have never been drunk (40.9 versus 32.6%) and weekly collaboration on household chores (85 versus 75.5%). The average daily hours of sleep were similar: 8.3 versus 8.1 in control (SD 1.34 and 1.16); also the daily electronic entertainment: 4.5 versus 4.3 in control (SD 2.37 and 2.27). Approximately three-quarters of students declared have had a couple and a third of both groups claimed to have had sexual intercourse with penetration. In these, the use of condom at the first intercourse was slightly higher in the intervention group (94.6 versus 87.5%), without significant difference, and similar in the last (79.6 versus 78.1%). Among those who did not have intercourse with penetration, the intention to use condom was similar.

SHE on students’ behaviour in Asturias

de Sevilla, 2008; Observatorio Espan˜ol sobre Drogas, 2009; Margolles and Donate, 2010). The limitations of this study were to use selfadministered questionnaires, with potential biases in the response, but they were assumed to occur in the intervention and control groups. Another limitation was the design of the study, simulating a longitudinal study and assuming effects of the programme on the fourth year without baseline. Therefore, possible selection and maturation biases cannot be ruled out. Finally and in conclusion, it seems that studying in a SHE may have some positive effect on students because the intervention group shows three healthier behaviours along with a better assessment of four school items. In total, 7 of the 25 variables were compared in this study. It shows an interesting trend and it would be necessary to move forward in order to improve the incorporation of the HEP in the school. There is sufficient evidence that a proper incorporation of the HEP in the educative centres, following the criteria and recommendations of the net SHE, produce positive effects on the students including health improvement (Lister-Sharp et al., 1999; McNeely et al., 2002; UIPES, 2003; Mukoma and Flisher, 2004; Lee et al., 2006; Stewart-Brown, 2006). This incorporation has been extensively detailed, also allowing the autonomy and creativity of the schools, and currently, a process with clear and concrete actions to become a SHE is available (Clift and Jensen, 2005; Gay et al., 2007; Garcia-Va´zquez et al., 2009a,b; Peters et al., 2009). However, in practice, the development of this process is still limited, due to the numerous difficulties involved (St Leger, 1999; Garcia-Va´zquez et al., 2009a,b; Gugglberger and Du¨r, 2011): lack of school time, training and participatory approaches, voluntariness of this type of actions, teacher staff temporary instability, poor curricular incorporation, absence of textbooks that include this perspective, etc. All of them could be summed up in one real reason for the poor development of the SHE: the lack of a clear commitment and a real action from the education and health authorities (St Leger, 1999; Mukoma and Flisher, 2004; Garcia-Va´zquez et al., 2009a,b; Gugglberger and Du¨r, 2011). Despite the evidence, previously discussed, and the numerous appeals for action from international organizations (Tang et al., 2008; St Leger et al., 2009), such as UN and WHO, the politician priorities are still focussed elsewhere. If we are really concerned with adolescent health and also their self-esteem, their empowerment

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fourth year where, in addition, the intervention group presents three healthier behaviours. This statement is also supported by the fact that the students of SHE better assess their school environment: greater satisfaction with the centre and the teaching staff, and also better perception of their school performance. These items are part of the process to become a SHE but they are also a result. In fact, when the adolescents study in an environment that promotes health their school performance improves (St Leger, 1999; Lee et al., 2006; Stewart-Brown, 2006). In order to reinforce this conclusion, there are two other effects on the fourth-year students that, although not significant, are better in the intervention group and suggest a consistent trend with the work carried out: the use of condom for the first sexual intercourse with penetration and the perception of feeling good about themselves. These differences are, as commented before, coherent with the issues prioritized in HEP in Secondary Education by the Regional Ministries of Education and Health. Specifically, these insti´ rdago!, tutions jointly offered the programmes ¡O about drug use prevention (Flores and Melero, 2003), and Ni ogros ni princesas, about sex education (Garcı´a-Va´zquez et al., 2009a,b). Both initiatives were developed by the schools in the intervention group but not in the control group. In relation to gender, the differences remain in the first and fourth year, and in both groups, in the practice of weekly physical activity. This topic is especially important, because the differences observed in the first-year increase in the fourth year, where boys maintain the level of activity while in girls it continues to decline. This fact is related to the different approach to this practice imposed on boys and girls from our society and also from the school which is linked to gender stereotypes and a difficulty of access for girls to do sport in general (Escalante et al., 2011). On the other hand, the perception of the school variables is better among girls. Yet, among the fourth-year students, another important gender difference appears concerning self-esteem: Girls feel worse about themselves, a result linked to gender differences. A clear example is still the pressure of the beauty model on girls, which makes it difficult to value themselves (Alemany and Velasco, 2008). In general, the results of this study show no major differences compared with other research studies focussed on students of the same age, which provides validity to the results (Universidad

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ACKNOWLEDGEMENTS This work was supported by Regional Ministry of Health of Asturias. The authors thank the students and teachers of the Schools for Health of Asturias, real protagonists of this project, for believing in this proposal and make it a reality. They are thankful to the schools that participated in this study and thank the teachers who helped in research. They also thank the staff of education (teacher centres), health, municipal and consumer training centres for their collaboration in the SHE programa. They also express their gratitude to Silvia Aguiar for her help and generosity.

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and the freedom of choice based on knowledge, a deep transformation of the educational system is required including the incorporation of a promoting health perspective in our environment, in the policies of the centre, in the curriculum, in the management team and teacher staff training and with the participation of the educational community. The voluntariness must give way to a concrete action plan, which includes actions, indicators and resources, to be developed in all the centres, following a steady process, but continuous and encouraging for people. This transformation, where health promotion is prioritized, includes the coeducational and ecological perspective and has numerous implications (Lee, 2009): on people’s health and well-being; on their education with the improvement of the school performance and the coexistence climate; also at the economic level with a lower consumption of sanitary resources in the medium and long term. In conclusion, by strengthening health promotion, it could be possible to move towards a healthier, more humane and sustainable society (Davis and Cooke, 2007).

SHE on students’ behaviour in Asturias Peters, L., Kok, G., Ten Dam, G., Buijs, G. and Paulussen, T. (2009) Effective elements of school health promotion across behavioral domains: a systematic review of reviews. BMC Public Health, 9, 182. Stewart-Brown, S. (2006) What Is the Evidence on School Health Promotion in Improving Health or Preventing Disease and, specifically, What Is the Effectiveness of the Health Promoting Schools Approach? Health Evidence Network Report. WHO Regional Office for Europa. Http://www.euro.who.int/__data/assets/pdf_file/0007/746 53/E88185.pdf. St Leger, L. H. (1999) The opportunities and effectiveness of the health promoting primary school in improving child health—a review of the claims and evidence. Health Education Research, 14, 51–69. St Leger, L., Young, I., Blanchard, C. and Perry, M. (2009) Promoting Health in Schools: From Evidence to Action. International Union for Health Promotion and Education.

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Tang, K. C., Nutbeam, D., Aldinger, C., St Leger, L., Bundy, D., Hoffmann, A. M. et al. (2008) Schools for health, education and development: a call for action. Health Promotion International, 24, 68– 77. UIPES. (2003) La Evidencia de la Eficacia de la Promocio´n de la Salud. Ministerio de Sanidad y Consumo. Universidad de Sevilla. (2008) Resultados del Estudio Health Behaviour in School-Aged Children (HBSC) con Chicos Y Chicas Asturianas de 11 A 18 An˜os. Ministerio de Sanidad y Consumo. WHO. (1986) Ottawa Charter for Health Promotion, http:// www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. WHO. (1997) First conference of the European Network of Health Promoting Schools. The Health Promoting Schools—An Investment in Education, Health and Democracy: Conference Report, Thessaloniki-Halkidiki, Greece, 1 –5 May 1997, WHO Regional Office for Europe, http://www.euro.who.int/document/e72971.pdf.

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

From 1995, Asturias participates in the European Network of Schools for Health (SHE); in 2010, the schools in net were 44 (11 of secondary school). Th...
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