Creating a Healthy School together: Building community capacity as a strategy for (sustainable) implementation of Health Promoting Schools

Dutch schools increasingly work towards stimulating healthy choices among adolescents through the Dutch Healthy School-approach. However, interventions and programs are difficult to sustainably embed and maintain in every day practice, and long term effects remain limited. In order to achieve (sustainable) implementation of Healthy School initiatives, it is advocated that the dynamic nature and the complexity of real-life practice needs to be embraced rather than avoided. Two central themes seem to arise when looking at indicators for successful implementation: a) contextualization is key to ensure that local initiatives are tailored to the dynamic and unique context of the school, and b) stakeholders in a school need to feel ownership and need to be empowered by means of leadership, collaboration and community involvement. In order for stakeholders to address these themes, a focus on the concept of ‘building community capacity’ can be an interesting strategy. This pertains ‘the development of knowledge, skills, ownership, leadership, structures and systems to enable effective health promotion’. Despite the fact that community capacity has long been recognized as an important indicator of program success, there is no simple, clear approach available to translate this into a strategy for practice, and to measure the development and impact of such a strategy. This dissertation aims to explore whether and how building community capacity can work as a strategy to (sustainably) implement a context-specific a broadly supported Healthy School-initiative in Dutch secondary schools. In the Fit Lifestyle at School and at Home (FLASH) intervention four prevocational schools in the Netherlands were encouraged to create a Healthy School community that specifically stimulated physical activity and healthy dietary behavior among pupils. The theoretical principles of FLASH are based on the Community Readiness to Change-method, resulting in four capacity-building strategies: 1) identifying and motivating leaders; 2) promoting a participatory school culture; 3) designing and implementing tailored health-promotion activities; and 4) creating a local network of collaborations and resources. Findings illustrated that these strategies, as explored in FLASH, can provide a reference to translate the concept of building community capacity to the real-life practice of Dutch secondary schools. By focusing on capacity-building, schools put more emphasis on the process of becoming a Healthy School that suits their unique and dynamic context. Engaging in continuous conversations about where to go and who and what is needed to get there, enabled stakeholders to move beyond organizing health-topic-specific activities and realize change is also needed on an organizational level. As a result, schools particularly increased their use of strategies concerning leadership and participatory school culture. At the same time, these efforts did not (yet) lead to improved health and health behavior among adolescents, and we observed a stagnation on the "initiation" stage of readiness in all capacity-building strategies. A contributing factor to this observation is that experiences of stakeholders in FLASH show that building community capacity is a long-term process and new focus for stakeholders, and therefore requires time to understand and grow. Because community capacity-building activities initially focus on organizational processes rather than directly stimulating healthy behavior through health promotion activities, delays in the system of a Healthy School community on health-related outcomes can occur. Nevertheless, it is worth engaging in a continued capacity-building process of a "Plan-Do-Check-Act" cycle that can potentially be sustained. By building on the expertise of professionals, the opportunities in and around the school system, and the needs and wants of community members, continuous improvement can be evoked so that schools get into an upward spiral. This can help stakeholders build a strong and professional Healthy School based on an integral approach that is embedded in the school's DNA.