Moving from health education tohealth promotion

Developing the health education curriculum inCyprus

Soula IoannouHealth Education Office, Ministry of Education and Culture, Nicosia, Cyprus

Christiana KoutaDepartment of Nursing, School of Health Sciences,

Cyprus University of Technology, Nicosia, Cyprus, and

Neofytos CharalambousInstitute of Development, Nicosia, Cyprus

AbstractPurpose – This paper seeks to discuss the rationale of the newly reformed health educationcurriculum in Cyprus, which aspires to enable not only teachers, but also all the school personnel, towork from the perspective of health promotion. It is a curriculum which moves from the traditionalapproach of health education focusing on individual lifestyle/behaviour modification into approachesthat recognise and tackle the determinants of health.

Design/methodology/approach – The paper critically discusses the structure and the content ofthe learning objectives of this curriculum that encourages teachers to work in a health promoting way.

Findings – The central goal of this curriculum is to enable students and schools to act as healthagents, addressing the structural determinants of health and promoting environmental changes. Theoptimum level for all topics of the curriculum is achieved through learning objectives, which concernthree interconnected levels. These are: “investigating determinants of health”, “practising actioncompetency skills for health” and “achieving changes in favour of health”. All levels are means as wellas end products in terms of the curriculum objectives.

Practical implications – Theoutcomeof thedevelopment of thehealth educationcurriculumactsasaguide for school interventions, through a methodological framework, which encourages participants toidentify and promote environmental changes that facilitate healthy choices. This is of significance tothose working in the field of health promotion and who seek to establish a new language of healthpromotion that goes beyond the pervasive discourse of individual lifestyles.

Social implications – The implementation of the particular health education curriculum willpromote not only health in the school community but also in the local community. This is because akey principle which underlies the curriculum is the involvement of the students, school staff, familyand community in everyday health promotion practice. It also promotes the development ofpartnerships among them.

Originality/value – This is an innovative curriculum for Cyprus, based on health promotion andhealth education principles, but at the same time taking in account the local socio-cultural and politicalperspective. This curriculum may be applicable to other European countries.

Keywords Health education, Health promotion, Curriculum development, Schools, Cyprus,Personal health

Paper type General review

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0965-4283.htm

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Received 15 November 2010Revised 22 February 2011

25 May 2011Accepted 20 June 2011

Health EducationVol. 112 No. 2, 2012

pp. 153-169q Emerald Group Publishing Limited

0965-4283DOI 10.1108/09654281211203420

IntroductionHealth promotion, a term more recent in origin than health education (Glanz et al.,1997), heralded a new phase in public health. It marked a transition from a traditionalstyle of health “education” to a promotion of health within the context of “new” publichealth (Beattie et al., 1993; Naidoo and Wills, 2009; Donaldson and Donaldson, 1993).While conventional health education centres upon the notion of personal prevention,health promotion suggests an emphasis upon social and environmental determinantsof health (World Health Organisation, 1986). The underpinning principle of healthpromotion is that “the health of individuals or social groups is the outcome of complexand interacting, material-structural and behavioural-cultural factors” (Katz andPeberdy, 1997, p. 33). Consequently, health promotion literature stresses the role thatstructural factors such as physical, social and cultural environments play ininfluencing children and young people’s health-related behaviours (Scriven et al., 2010).

This broader focus is reflected in the main strategies and ideas that characterisehealth promotion within the school context (Boonen et al., 2009; Vilnius Resolution,2009). It generated a shift from traditional formal learning style approaches toorganisational and structural ones which consider the role of the socio-cultural andphysical environment in facilitating healthy choices (Rowling, 1996; Tones, 2005).

Deschesnes et al. (2003, p. 388) argue that the literature regarding health promotionat school level generally focuses on the move “from practices that rely mainly onclassroom based health education models to a more comprehensive, integratedconstruct of health promotion that focuses both on children’s attitudes and behaviours,as well as their environment”. Particular attention is given to the creation ofcooperative partnerships between teachers, students and parents (McNeely et al., 2002)so that all are involved in efforts, both to improve a child’s health and redefine acommunity’s participation as a health development agent (International Union forHealth Promotion and Education, 2008, 2009; Paulus, 2009). School-based healthpromotion aims to strengthen young people’s ability to contribute to the creation of ahealthy community (Stokes and Mukherjee, 2000), by introducing activities that enableschool-aged children to develop the essential knowledge and social skills for informedchoices regarding their physical and psycho-social health.

Despite this shift in emphasis, in which school-based health programmes purport toaddress structural determinants of health, schools and education establishments oftenfind themselves unable to move on from traditional models of health education whichaim to bring about behavioural change (Colquhoun, 2005; Colquhoun et al., 2008; Pikeand Colquhoun, 2010). Many succeed in increasing public knowledge about personalhealth-related behaviours, but not in raising students’ awareness and capacity to tacklethe causes and complexities of health-related behaviours, which include the structuraldeterminants of health, such as housing, poverty, environment and education in additionto individual lifestyle factors. Deschesnes et al. (2003) Without downplaying any form ofhealth education, we argue that there is a need for a shift in focus from behaviour changeto environmental change (Nutbeam, 2008; Ioannou, 2005; Simovska, 2007)

This paper aims to critically discuss the structure and content of the new healtheducation curriculum for primary and secondary public schools in the Republic ofCyprus (Ministry of Education and Culture, 2010). It discusses three levels of “learningobjectives” and the main thematic areas included within the health educationcurriculum. Furthermore it describes how the curriculum is structured in order tosecure its health promotion aspirations. It does not merely argue for a health promotionapproach, but suggests how this direction can be fulfilled through a school health

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education curriculum. In particular, this article describes the challenge of the healtheducation curriculum in encouraging staff, students and parents to promote healthrather than relying upon traditional forms of health education which concentrate onmoralistic behaviour changes. The underpinning goal of the curriculum is to encouragestudents’ participation as active health agents who are able to address the structuraldeterminants of health and promote environmental changes.

The paper consists of two parts. The first part describes the main components of thehealth education curriculum including: learning objectives, content, teaching/learningmethods and evaluation. The second part discusses these components in relation tosome key dominant principles within health promotion theory and practice:“overcoming victim blaming”, “achieving in-depth knowledge”, “empoweringindividuals as health agents” and “empowering schools as health agents”. Theultimate goal of the new health education curriculum is the provision of guidance forschools, which, we suggest, can aid schools to work in a health promoting ways. Itenables pupils, parents and staff to be actively involved in setting health-related goalsand in taking actions at the school and community level, to reach these goals.

The health education curriculum development in CyprusThe need for a systematic inclusion of health education in schools required theengagement of the Ministry of Education and Culture in educational reform in Cyprus(Ministry of Education and Culture, 2010). When the government decided to proceedwith the Educational Reform of the School Curriculum, a health education curriculumwas created and given importance by the authors and a group of teachers. The newlyproposed curriculum will be piloted in a selection of schools (during the academic year2010-2011), evaluated, and then gradually implemented across the whole of Cyprus(primary and secondary education). Currently, health education in Cyprus is not taughtas a separate subject, but as a cross-curricular subject, mainly through biology andhome economics. Nevertheless, the need for the development of a new and separatehealth education curriculum which overcomes the individualistic approach to health isincreasingly evident. The reasons for this are briefly elaborated below.

Cyprus, like other societies, faces a number of social and health-related problemssuch as increased reported rates of smoking, alcohol use, sexually transmitted diseasesand delinquency (the European School Survey Project on Alcohol and Other Drugs(ESPAD), 2000; Papadopoulos and Constantinopoulos, 2005; ASTRA Network, 2006;Bathrellou et al., 2007; Stylianou, 2007; Christophi et al., 2008; Lazarou et al., 2008;Lazarou et al., 2009; Karekla et al., 2009). To address this a number of nationalprevention strategies have been developed (such as the Drug Prevention Strategy2009-2012, Crime Prevention Strategy, 2006-2010, Action Plan for Violence AgainstWomen), each including health education as a key component within the Cypruseducational system. In addition health education is included in the public schoolregulations (primary and secondary) (Ministry of Education and Culture, 2005).

The Ministry prioritised health by supporting health education programmes. Forinstance, the European Network of Health Promoting Schools (ENHPS, 1997) began inCyprus with five schools in 1995 and at present more than half of Cypriot schoolsparticipate. The expansion of health education programmes led to the decision of theministry to ask each school to create their own health education committee which isresponsible for the development and the implementation of an action plan for healthpromotion that is acceptable to both the students and school staff. The Ministry of

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Education and Culture in Cyprus encouraged schools to adopt a more organised andstructured approach, taking into consideration the role of the socio-cultural andphysical environment in influencing the well-being of the students (Ioannou andKalakouta, 2006). For this, in service training on health promotion was provided andfunding was available to schools that intended to implement relevant activities.

The successful Cypriot participation in “Shape Up – a school community approach toinfluencing determinants of a healthy and balanced growing up”[1], a school basedhealth promotion project delivered in 19 cities across Europe (Simovska et al., 2006;Simovska and Jensen, 2009a), was also significant in the development and the societalorientation of the HE curriculum. The “Shape Up” project aimed to address the structuraldeterminants of children and young people’s health as well as challenge traditionalpreventative interventions that focus exclusively on children and young people’s healthbehaviours. The investigation-vision-action-change (IVAC) participatory approach(Jensen, 2004; Simovska et al., 2006) was adopted to encourage student participation.Findings from the Cypriot case studies demonstrated schools’ potential to work inhealth-promoting ways by empowering school communities to create environmentsconducive to health, where individuals were more able to take care of their health, ratherthan simply implementing healthy activities at school (Pike, 2008; Colquhoun et al., 2009).Actual school examples from the Shape Up project (Pike, 2008), as implemented inCyprus, will subsequently be used to provide a practical illustration of the ways thatstudents are expected to work within the health education curriculum.

The health education curriculum: an overviewThe proposed health education curriculum is directly related to the introduction ofhealth promotion in the field of education in Cyprus. The challenge was to develop acurriculum which encourages students, parents, staff and others, within thecommunity to work together and bring changes that are beneficial to their own andto others’ health. The emphasis is not on how to persuade the individual to changebehaviour but how to empower individuals to collaborate, develop partnerships andcreate supportive environments conducive to health.

The structure of the curriculum has been developed in order to facilitate its healthpromotion aspiration and simultaneously counteract the individualistic perspective ofhealth education. The structure consists of three levels of learning objectives and fourmain thematic areas (see Figure 1). The levels correspond to learning objectives and thethematic areas to the content. It is a curriculum which is built on “social learning”,“action competence skills” and “theory of change”: concepts which characterise healthpromotion and correspond to the three levels of the learning objectives of thecurriculum. The structure of the curriculum is subsequently discussed as it ispresented in Figure 1. The three levels correspond to the three concentric circles whichpass through the four thematic areas.

The learning objectives and the content of the curriculum have a grade-to-gradeprogression by grades:

(1) Grade 1: 5-8 years old, Preschool Class A, B.

(2) Grade 2: 8-10 years old, Class C, D.

(3) Grade 3: 10-12 years old Class E, St.

(4) Grade 4: 12-14 years old Class A, B Gymnasium.

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Figure 1.The model for developing

the Cyprus healtheducation curriculum

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Levels of the curriculumThe goal of the curriculum is to enable students in collaboration with “significantothers” to act as health agents, addressing the determinants of health and promotingchanges which facilitate healthy choices. The main goal of the curriculum was placedat the centre of three concentric circles (see Figure 1). Each circle represents one level ofthe learning objective of the curriculum. The first level is entitled “Investigatingdeterminants of health”, the second “Practicing action competency skills for health”and the third level “Promoting and achieving changes”. All levels act as a means aswell as end product in terms of the curriculum learning objectives. The ordercorresponds to the three phases that the students are expected to experience, in order tobecome future health agents, who can promote the changes that facilitate health.

Level 1: Investigating the determinants of healthThe first level, represented with the outside circle in Figure 1, includes learningobjectives, which concerns social learning as a school process. This aims to enablestudents to become aware of the complex interplay of economic, social, politicalcultural and environmental factors that affect health, health-related practices andbehaviours mainly among youth. Students become aware of how lifestyle, environmentand society influence their health and their choices. They are expected to realise theways in which the surrounding environment and society create frameworks, whichaffect individual’s health and health-related behaviours (such as smoking and eatinghabits). Media, social class, areas of living, peer pressure, family, corruption, money,bureaucracy, law, culture, restaurants’ menus, knowledge and community services arestudied as determinants of health at this level.

The curriculum takes as its starting point the social learning that occurs in the livesof young people. At this first level, students have the opportunity to critically elaboratethrough their personal experiences, implement small-scale research projects andcritically discuss research evidence of the factors that influence health. These learningprocesses facilitate students to develop a deeper understanding of the protective andrisk factors associated with both social and health problems such as injuries, substanceabuse, obesity and bullying. They will also have the opportunity to learn about thecomplex interrelationship of these factors.

The learning objectives at this level are progressive. Younger students are expectedto identify and discuss factors which influence for instance their growth, emotions,lifestyle choices through exchanging their own personal observations and experiencesof their immediate environment. Older students are expected to discuss researchevidence regarding health-related behaviours. Consequently, it is intended that theydevelop a critical perspective of social inequality. The examples below illustratelearning objectives of the first level regarding health and food:

. to compare their eating habits at different settings (school, home, birthdayparties etc) (5-8 years old);

. to elaborate eating habits of the different cultures (8-10 years old);

. to develop small-scale research concerning the factors influencing the eatinghabits of young people (10-12 years old); and

. to discuss critically research evidence concerning obesity (12-16 years old).

The identification of health determinants is expected to evolve naturally amongstudents, parents and teachers as an outcome of the learning objectives within the first

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level of the curriculum. For example, “unappealing playground area”, “lack of facilitiesin playground”, “traffic”, “road safety”, “heavy school bags”, “lack of bike sheds”, “lackof lockers in school”, “unhealthy meals provided by local bakeries”, “boring healthyproducts provided by the school canteens”, “absence of municipality willingness”,“bureaucracy”, “lack of transportation”, “lack of money” and “local restaurants’menus” were some of the barriers to good health within the school and communityenvironment that were identified and elaborated by students who participated in theShape Up project.

Level 2: practicing action competence for healthThe second level of learning objectives, represented by the middle circle in Figure 1,concerns the development of action competence. Action competence refers to the abilityto act, initiate and bring about changes with regard to health ( Jensen, 1997; Simovska,2007). The development of action competence empowers students to bring abouthealth-related changes. At the second level, students in collaboration with parents orother agencies of the community work together to bring changes regarding their livingconditions: a process which strengthens their action competence. This level includesmainly civic activities, which are often a pre requisite for promoting environmentalchanges. These are for instance, persuading key decision makers, market research,getting feedback from others, exchanging ideas, school and community collaborationneeds assessment, forming a budget and so forth. These refer to mainly essentialcommunity procedures, which enable citizens to bring about changes within thecommunities.

For instance, in the sub-thematic area of food, students may collaborate withparents to change the menus of the local restaurants in order to create menus which arehealthier, but at the same time they are attractive to young people. Throughout thisprocess students are expected to negotiate with the owners of the local restaurants,pursue advice from chefs and possibly advertise the new menus. These are skills whichconcern the learning objectives of the second level as seen below:

. to apply strategies and skills needed to attain a personal health goal (aged 8-10);

. to encourage others to make positive health choices (aged 10-12); and

. to collaborate with “significant others” in order to make the neighbourhood closeto their schools conducive to physical activity (aged 12-14).

The learning objectives within the second level of the curriculum require actions.Students at this level are expected to increase their knowledge of local decisionmaking processes and develop skills that enable them to act and bring abouthealth-promoting changes. For instance, Shape Up participants developedpartnerships with a national sports federation, pursued funding, arrangedtransportation, presented their visions to key decision-makers, wrote formal lettersto several organisations (e.g. Ministries and Police), did market research, and soughtadvice and co-operative partnerships (e.g. from parents’ association, localtechnicians and horticultural experts). These are actions needed to bring about“real life” (Simovska, 2007) changes within the living conditions of students. Theseactions, included in the second level of the curriculum are necessary healthpromotion experiences for students and teachers in order to experience real life andbring about changes, which facilitate health.

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Level 3: achieving changes that favour healthThe third level of learning objectives, which corresponds to the inner circle of thecurriculum, refers to environmental changes which facilitate health. The learningobjectives of the second level are not concerned with achieving changes, but withpracticing and developing action competence skills, which are conducive to health.

The third level refers to the potential of schools to act as health agents and tofacilitate changes. Each school has a role within the community and the curriculumaspires to promote this role. The emphasis as stated earlier is not on the behaviourchange as a result of individual knowledge and effort. The focus in this level refers toenvironmental changes as expressed in the Ottawa Charter for Health Promotion(World Health Organisation, 1986) where “creating environments conducive to health,in which people are better able to take care of themselves” (Epp, 1986). Developmentsin health promotion have suggested that behaviour change as a matter of personalknowledge and thus responsibility was seen as inadequate and “unfair” for the role ofindividuals in health matters (Tones, 2001).

Maintaining the consistency of the curriculum across all school grades, providesstudents with the opportunities to work collaboratively for a change within theirenvironment. For example, in the topic area of safety, the learning objectives urgestudents to collaborate with their parents in order to make their living environmentsafer. For instance, students at grade 2 having checked their house may decide toremove the cleaning liquids from the cupboard under the kitchen sink. Students atgrade 4 may argue formally to the municipality for safer parks within theirneighbourhood.

The Health Education Curriculum allows students to initiate and bring about suchreal life changes. The capacity of schools to bring about changes in their surroundingenvironment (school and community) in order to facilitate healthy choices wasexperienced in Cyprus through the Shape Up project. For instance, playground areaswere enriched with games equipment, school canteens and local youth restaurantsincluded healthy and “youthful” options, free swimming and ping pong lessons werearranged for students and personal lockers and bicycle storage areas were developed inorder to allow students to store their heavy school bags and use the walkway and cometo school either by bike or on foot. Students are able to choose healthy snacks andexperienced a greater level of body movement including, walking to school, cycling toschool, swimming lessons, sports activities, games during break time and ping pong.These healthier opportunities are achieved by encouraging and facilitating students tothink about their living conditions, to visualise desirable changes and act aboutchanges in their surrounding environment. Correspondingly, the curriculum aims toallow students to initiate and bring about real life changes which can facilitatehealthier options.

Content of the curriculumAll topics of the curriculum are classified into four thematic areas:

(1) Development and empowerment of one’s self.

(2) Development of a healthy and safe lifestyle.

(3) Development and improvement of one’s social self.

(4) Development of an active citizen.

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These thematic areas and their sub-thematic areas provide a holistic perspective ofhealth, since they includes all dimensions of health. In Figure 1 the content of thecurriculum corresponds with the square which is divided into four squaresrepresenting the four thematic areas. The three concentric circles which show thethree different levels of the curriculum are included in all squares.

The curriculum content and its objectives do not concentrate only on thetransmission of knowledge of what is “good” for health or not, but as it is shown in allthree levels, on identifying with the students the factors that influence healthybehaviour through different actions. A conscious decision was taken to avoidinformation overload in the curriculum and the emphasis was based on the explorationof self and society. The three levels are interrelated and place an emphasis on theenvironment of the student (immediate and extended). The correlation of all topics withthe student’s environment and the development of life skills that concern the demandfor improved lifestyle (and health) are common in all thematic areas. For example,skills such as assertiveness, critical analysis of the factors that influence health orhealthy behaviour and the role of the individual in a society with congruent life valuesexist as content and learning objectives in the thematic areas.

Teaching and learning methods and evaluationThe curriculum determines the teaching, learning and assessment methods which arebriefly elaborated in this section. In particular, we focus on the social learning, activeparticipation and the structural approach. These three methodological characteristicsof the curriculum are elaborated to identify their health promotion aspiration.

Social learning is the learning in the process of socialisation and growing. Sociallearning develops opinions, attitudes, values upon which people base their lives andactions. Social learning at a school level aims to stimulate students to think critically,visualise their own potential and be conscious of their social responsibilities (Payton et al.,2000). Social learning is a methodological tool for the curriculum. The health educationcurriculum requires methods which support social learning. The starting point is thelearning that occurs in the lives of young people. It encourages students through itscontent and objectives to explore and think about issues that relate to their own lives andtheir immediate and expanded environment. The particular objectives of the first levelenable students to critically discuss research and review matters connected with theirown lifestyle and their environment. Social learning acts as a prerequisite which enablesthem to have an impact in their everyday life regarding their choices on health. The level1 of the curriculum “investigating determinants of health”, as described above,encompasses learning objectives which encourages social learning regarding health.

In the school environment the term “active participation” is often used to mean theinvolvement and participation of students in set activities, without taking intoconsideration the real influences on them (Simovska, 2005, 2007). Ideally activeparticipation should refer to encouragement, guidance and support by teachers of theirstudents in a constructive (and not just symbolic) influence. This influence,consequently affects their lifestyle and health in its immediate or extendedenvironment (Simovska, 2005, 2007; Simovska and Jensen, 2009b). In this sense, thepresent curriculum promotes active participation mainly to the second level of theobjectives. This include teaching methods which support active learning andcooperation peer learning such as dialogue, role-play, games, stories and projects.Verbal expression, information gathering, independent thinking are part of this

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process. The active participation is an essential practice for individuals to developaction competence skills (see level 2). Learning and teaching which takes into accountthe view of students and their experiences, particularly where decisions impact theirlife choices, are important. The level 2 “practicing action competency skills for health”,as described above, includes learning objectives that stimulate students to collaboratewith others people, most obviously parents and teachers, and promote public health.

Health promotion on a school level represents one of the significant challenges to thetraditional models which focus on behaviour modification in relation to health. In contrastthe structural approach refers to the holistic approach that teachers, students and parentsshould follow in order to facilitate environmental changes which are conducive to health.The health education curriculum requires contributing in the interaction with otherstructural components of the school. For this purpose, the proposed curriculum refers toeducational and managerial actions not only in the classroom but also in policydevelopment (e.g. for diet, bullying), as well as partnerships with the community, andcollaboration with parents. These promote a holistic perspective, participation andempowerment of the whole school community and the community in general.

The structural approach of the curriculum is expressed mainly through the third levelof the learning objectives. As described above, students are expected to collaborate withsignificant others and bring changes within the settings of their everyday lives. The casestudies provided (level 3) refer to changes within the school or community environment.The central concern is not what makes individuals ill or healthy, but what creates healthin populations. The emphasis is on bringing environmental changes which supportindividual behaviour changes. This approach, which concentrates not on the individualbut on the settings of everyday life, reinforces the healthy school approach.

The health promotion aspiration of the curriculum needs a corresponding approachto assessment. As Simovska and Jensen (2008) suggest, health promotion at schoolsfocuses on educational as opposed to narrowly defined (e.g. behaviour modification)health outcomes and the teacher is expected to reflect and self-evaluate the teachingprocess and not just to search for the impact of the teaching on an individual student’sbehaviour. In line with this, the learning objectives of the curriculum referred toeducational expectations and capacities and not to behavioural changes. For example,it is expected that anger management will be taught, but how a student will actuallyapply it depends on many parameters, in and out of school.

Self-evaluation is also suggested as a methodological tool for the curriculum. Selfevaluation is promoted amongst students through a self reflective and critical thinkingapproach which considers their own and others’ health. Students, parents and teachersare expected to present collectively their achievements and all the actions, barriers andideas that occur while accomplishing their vision.

DiscussionThis paper presents a health education curriculum that prioritises the determinants ofhealth and promotes environmental changes in addition to behaviour change. Thecurriculum has been developed by taking into consideration the difficulty that schoolsface in enacting health promotion principles. In this section, we discuss the benefits of ahealth education curriculum, which integrates health promotion principles. Inparticular we discuss the benefits of the curriculum in the context of Cyprus in relationto some key “mantras” within health promotion theory and practice: “overcoming

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victim blaming”, “achieving in-depth knowledge”, “empowering individuals as healthagents” and “empowering schools as health agent”.

Overcoming victim blamingHealth education as a school subject has been accused of victim blaming (Ewles andSimnett, 2003). In conventional health education, individuals are expected to evaluatetheir risks of succumbing to disease and to take responsible decisions (Seedhouse, 1997).People’s failure to control their daily behaviour is attributed to a lack of the knowledgeand skills to prevent from potential harm associated with certain aspects of everydaybehaviour. This is what Colqhuhoun and Kirk (1987) have referred to as the ideology of“healthism” which has emerged in the curriculum. The development of health promotionis typically represented as a reaction against both excessive responsibility which isplaced on individuals concerning their health-related choices and the victim-blamingapproach of traditional health education (Lupton, 1995; Donaldson and Donaldson, 1993).

The challenge for the present curriculum is to avoid such a dogmatic approach or inother words the fear and victim blaming of human health behaviour (such as thatassociated with obesity or smoking). In the proposed curriculum, the role of theindividual is not overlooked, but it is placed in its wider social context. Students havethe opportunity to learn about the biomedical relationship of individuals’ behaviourand health. Yet, this sort of information does not occupy the entire content of thecurriculum. As it is described above, the first level of learning objectives ensures thatstudents have the opportunity to think critically, exchange opinions and investigatefactors that influence the behaviour of the individual. During this phase, the studentshave the space and time to consider factors that may also determine their ownbehaviour. The learning objectives of the curriculum do not focus on the individual buton factors that influence the behaviour or the level of health of a social or geographicalgroup. Students have, for instance, the opportunity to discuss the cultural values of thecommunity and how these cultural values influence the behaviour of young people: aprocess which enables them to think critically about their behaviour without fear ofexposure. This process gives students the opportunity to think about their ownbehaviours without blaming themselves or others while enabling social learning.

In summary the process described above, helps students to recognise that health isas much a government responsibility as a personal matter, and that they are expectedto understand the factors influencing health find solutions and create a supportiveenvironment for health.

Achieving in-depth knowledgeIt is widely known that learning is more substantial when it incorporates doing(Scriven et al., 2010). Doing is part of knowing and knowing is part of doing in realsituations. This is what this health education curriculum aims to achieve. It aims toprovide opportunities for students to learn actively through situations that interest,concern and relate to them. Students do not merely have the opportunity to becomeaware of local decision making processes that affect their health and how these operate.They are expected to practice skills, to take responsibility for achieving change in theirschool or locality, and to work together to achieve common objectives. Students areexpected to play an active part throughout the process which is continued until achange that affects their health is achieved. These processes are not learned throughtraditional classroom activities, but through a real experience in real situations (Ewlesand Simnett, 2003). The focus on students’ lived experiences is conducive to learners’

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motivation and commitment to contribute, to learn and act in collaboration with others(Simovska, 2007, 2008), learning that is always situated in students’ context. It is sociallearning, which builds on students’ ability to actively take part in shaping instead ofsimply receiving knowledge.

Empowering Individuals as health agentsThe potential of the curriculum to foster students’ action-competence, their ability tobring about positive change with regard to health, provides new value for thehealth-promoting school approach. This health promoting approach ( Jensen, 1997;World Health Organisation, 1997) attempts to enhance students’ capacities to deal withthe complexity of health issues and to participate competently in rapidly changing,fluid social realities. The emphasis is, or should be, on the development of students’action competence, including their ability to bring about positive change with regard tohealth ( Jensen, 1997). From the health promotion perspective, students are expected tomake a difference, to bring change as opposed to conform to instructions like “avoidfatty food” and “exercise more”.

The curriculum provides the opportunity for students to practice action competenceskills in real situations (as previously discussed in level 2). It urges students tocollaborate with others, such as parents, teachers and community members, andachieve changes which relate to their own lives and the school, neighbourhood orcommunity context. Throughout the curriculum students learn about factors whichinfluence their health, develop actions and promote changes in their everyday life notonly for themselves but for their community too. Thus, students improve theirunderstanding of healthy lifestyles and their capacity to change things. It promotesamongst students, parents and students self-reflection and critical thinking approacheswhen considering their own and others’ health.

All these experiences prepare young people to play a responsible role in societywhere health matters are of major concern. It is a curriculum which aims to developstudents into self- confident individuals, who can think critically, visualise their ownpotential and be conscious of their social responsibilities. It is a curriculum whichaspires to give students the necessary skills, information and above all, the confidenceto negotiate with society. Furthermore, it develops the personal empowerment ofstudents, teachers and parents to act as health agents.

The curriculum promotes changes which are suggested and implemented throughstudent collaboration and capacity building (Scriven et al., 2010). The ownership of thecurriculum is transferred to the students, not as individuals but as members of society,with the right to contribute to society and to the decisions which affect them. Thecurriculum provides an opportunity for students to realise the benefits of collaborationin order to promote changes rather than attempting on their own to change theirpersonal behaviour.

Empowering the school as a health agentThe curriculum supports schools to act as health agents in two ways. First of all itsupports the development of partnerships that prioritise health as a significant concernand secondly it provides an environment which is conducive to health.

Firstly, the school acts as a health agent because it gives the opportunity to itsmembers to develop partnerships for health. The curriculum empowers students,parents and staff to collaborate and bring changes within their own context regardingmatters that relate to them. Students, parents and staff become health agents together

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for their own school, neighbourhood and community. School partnerships depart fromstrategies which aim to persuade the individual towards behaviour change, tostrategies which tackle the determinants of health. The curriculum directs schools toaddress the structural determinants of health and bring about changes in livingconditions which can support changes in lifestyles. For example, school partnershipsmay promote such changes in schools or community areas which support thestrengthening of relationships. The curriculum may also promote changes in, forexample, the canteen menu, local restaurant menus, and in the local parks, which canpromote environments conducive to healthy choices.

Secondly, a school as a health agent refers to a school environment, which is safe,healthy, friendly and thus conducive to health, a school that facilitates a healthier,friendlier and safer choice. Students and staff have the opportunity to feel that they arelistened to and feel secure in their ability to discuss sensitive aspects of their lives. Thecurriculum promotes a school which has a positive climate in which children andyoung people feel safe and secure. They have experiences in modelling behaviourwhich promotes health and well-being. The curriculum cultivates collaboration, selfconfidence and self respect as students have a specific role to play within the school.

The concept schools acting as health agents is in accordance with the healthpromoting school approach (IUHPE, 2008, 2009; Vilnius Resolution, 2009). It stimulatesthe empowerment of the school community to take ownership of the health of itscommunity. It also provides settings (such as healthy school policies, the school’sphysical and social environment, community links and health services) which supportnaturally the health of its population.

DilemmasThere is a need to evaluate the potential benefits and drawbacks of such a curriculum. Thecurriculum aspires to environmental changes, in addition to individual ones. Can students,parents, schools be responsible for changes in the broader society? Can they have a role?Can they have a shared responsibility? There may be a danger of overestimating theirpotential to promote changes. Everyone within each learning community, whatever theircontact with children and young people may be, shares the responsibility of creating apositive ethos and climate of respect and trust – one which everyone can make a positivecontribution to each individual’s well being within the school and the wider community.

Lastly it should be stressed that more systematic research, evaluation about thelong-term effects of the curriculum is needed.

ConclusionHealth promotion challenges the exclusive emphasis on the individual following ahealthy lifestyle as the key factor in securing health (Scriven et al., 2010; Tasker, 1992).The role of the individual to maintain their health is not neglected but the individual isseen within his or her socio-cultural context (WHO, 1986). Although the roles of thesocial determinants of health have been identified for many years, there is a gap in ourknowledge about the strategies needed to address these factors in health promotion(Mohajer and Earnest, 2010). Within the framework of the traditional forms of healtheducation, there is often a lack of criticism and an acceptance of certain world-views.Many a time these world-views are too narrow.

The Cypriot health education curriculum discussed in this paper can becharacterised as an attempt to acknowledge the socio-cultural context of health and

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provide solutions. It provides solutions in the sense that it approaches healthpromotion as a driver for social change by energising the capacity of schools as healthagents to take action locally. The curriculum, through its different levels of learningobjectives, has the delicate task of encouraging a critical and democratic outlook instudents and at the same time, not alienating them from their own milieu. It promoteshealth and sustainable development by capitalising on the student voice and a sense ofcollective ownership of the context. The balance between society and the individualthat health promotion demands is expressed in the present curriculum with activitiestargeting simultaneously the empowerment of the individual and the development ofsupportive environment in school and in the community.

Note

1. The project was coordinated by P.A.U. Education, Barcelona, and co-financed by the EC, DGSANCO. More about the project organisational structure and funding on: shapeupeurope.net

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Further reading

Blaxter, M., Beattie, A., Gott, M., Jones, L.J. and Sidell, M. (1993), Health and Wellbeing: A Reader,The Open University, London.

Clift, S. and Jensen, B.B. (Eds) (2005), The Health Promoting School: International Advances inTheory, Evaluation and Practice, Danish University of Education Press, Copenhagen.

Glanz, K., Lewis, F.M. and Rimer, B.K. (Eds) (1997), Health Behavior and Health Education:Theory, Research and Practice, Jossey-Bass Publishers, San Francisco, CA.

Horschelmann, K. and Colls, R. (Eds) (2010), Contested Bodies of Childhood and Youth, PalgraveMacmillan, Basingstoke.

Reid, A., Nikel, J., Jensen, B.B. and Simovska, V. (Eds) (2008), Participation and Learning.Perspectives on Education and the Environment, Health and Sustainability, Springer, Newton.

Scriven, A. and Orme, J. (Eds) (2001), Health Promotion: Professional Perspectives, Palgrave inassociation with The Open University, Basingstoke.

Sidell, M., Jones, L., Katz, J. and Peberdy, A. (Eds) (1997), Debates and Dilemmas in PromotingHealth, Macmillan Press, London.

Whitman, C.V. and Aldinger, C.E. (Eds) (2009), Case Studies in Global School Health Promotion,Springer, Newton.

Corresponding authorSoula Ioannou can be contacted at: soulaioannou@cytanet.com.cy

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