Accreditation of schools as Health Promoting Schools and Health Profile Assessment of Selected Accredited Schools in a Northern City of India

Background: Accreditation is a public recognition of the achievement of required standards by an organization. It certifies the schools for their efforts in implementing health promotion initiatives following an assessment, further helping them in redeveloping and implementing effective HPS strategies. Methods: The current study was conducted in 206 schools of Chandigarh with the objective of assessment and classification on accreditation level (bronze, silver, gold and platinum levels) as health promoting schools; intervention for one year for further quality improvement and reassessment after one year from 2016-2019. Interventions in the form of capacity building, technical visits, supportive supervision to schools, sensitization of policymakers and key stakeholders, implementation of policy initiatives, use of social media, technical support and monitoring of activities) were provided to all schools. Comparative health profile assessment was undertaken 754 children from higher and 700 children from lower accredited schools by GSHS questionnaire. Results : Out of 206 schools, 203 participated in the baseline and 204 in endline assessment. The response rate was 99 %.Two schools which refused participation were excluded and not assessed. Schools (N=17) which participated in the 2011-2013 study were excluded from analysis. There was a statistically difference (p=0.01) in the improvement of accreditation level of the baseline and endline assessment (p<0.05). Overall, the proportion of schools at the gold level increased from 1(0.5%) in 2016 to 71(38%).Silver level from 9(5 %) to 57 (31%) of schools after intervention. The response rate in health profile assessment in higher and lower accredited schools was 95.9% and 92.7% respectively. The health profile higher accreditation level schools (N=754) were found better in hygiene practices protective factors (peer support at school, parental or guardian supervision), handling stress and less prone to injury as compared to lower accreditation level schools (N=700), (p<0.05). Conclusions: The schools accreditation was feasible and lead to significant improvement in accreditation level as compared to baseline assessment (p<0.05).The Health profile assessment was also found to be better in higher as compared to lower accredited schools.Therefore, the accreditation

system was found to be feasible, effective and beneficial in terms of improving health profile of children in the school setting.

Background
The health of children and adolescents is of supreme importance to the growth and development of any country. Along with the family, the school is one of the main settings in which individual and social development occur [1]. The interaction between school teachers and students provides a unique opportunity for health promotion that can be sustained and reinforced over time [2]. Hence, school is an appropriate setting to improve youth health.
The "Health Promoting School" (HPS) is a holistic approach to integrate health promotion within the community. The concept of 'Health Promoting Schools' was adopted by the World Health Organization (WHO) in 1995, as part of a settings-based approach to health improvement. In Europe, North America, and the Western Pacific region, there have been significant developments in the promotion of children's health involving schools [3].
In India, a pilot activity for accreditation of 'Health promoting schools' was undertaken under the umbrella of WHO, Health Department of Chandigarh, Ministry of Health & Family Welfare, ICMR, Quality Council of India and Principals of School at Chandigarh in 2010-11 in which a checklist and scoring indicators were developed and 17 schools were assessed and accreditated [2].
Accreditation is a public recognition of the achievement of required standards by an organization. [4] It certifies the schools for their efforts in implementing health promotion initiatives following an assessment, further helping them in redeveloping and implementing effective HPS strategies. Four categories of accreditation were formulated namely, Platinum, gold, silver, and bronze in the pilot study [2].
The current study was conducted to assess and classify all private and government schools located in Chandigarh for accreditation as health promoting schools and comparative health profile assessment of selected accredited schools under the project funded by Indian Council of Medical Research.

Methods
The present study was a quasi-experimental conducted in 206 schools (public and private) in Chandigarh city from September 2016 till May 2019. Meeting with key stakeholders viz Education Secretary and Director Public Instructions, School health program officer, Chandigarh Administration were held for ensuring their active participation and permission was taken for the study. Sensitization and training of cluster resource centre coordinators (CRCCs) from Education Department, Chandigarh Administration were held. Each CRCC deals with 4-6 schools located in the area designated to them.
Manual developed in an earlier pilot study (2011-2013) was reviewed and accreditation checklist in the manual was modified in order to assess 8 domains: (Healthy School Environment, Mechanism for promoting health in schools, School health services, School nutrition services, Physical Education, School counseling, psychological and social services, Community partnership, Implementation of Shala Siddhi and mentoring schools in becoming HPS ). Cut-off scores for bronze, silver, gold, and platinum levels are categorized as 100-120, 121-150, 151-200 and > 200 points, respectively, as per the standards developed in the previous study. [2] Two training workshops were conducted to train the assessors in understanding the process of assessment and accreditation of schools as HPS. After the consent of school authorities, the assessment date was scheduled as per the convenience of school authorities. For baseline assessment, a team of 3-4 assessors was constituted for carrying out assessment activities in each school. A brief introduction session was held with school authorities before beginning the assessment.
Documentation verification was conducted, followed by a physical assessment of the school infrastructure. Debriefing sessions with school authorities were conducted at the end of the assessment. Ethical permission for conduction of study was taken from the institutional ethics committee.

Data analysis:
The data collected was entered in excel spreadsheet and analyzed by using SPSS ver 20 and Epi info.
Initially, the data was screened for missing and outliers. Descriptive statistics was used to describe the study demographics using frequencies (n), percentages (%), means, and standard deviation (SD).
Chi-square was used to examine differences among variables.

Results
All schools in Chandigarh city (N = 206) were invited for participation in the study of the ICMR funded project. Out of 206 schools, 203 participated in the baseline assessment and 204 in the endline assessment. Two schools which refused participation were excluded and not assessed. The response rate was 99%. Schools (N = 17) which participated in the 2011-2013 study were excluded from analysis [2]. Data of government schools (N = 113) and private schools (N = 74) was analyzed.
Distribution of schools showed that there were more high schools (49%) as compared to senior secondary schools (32%) among government category (table-1). Overall, there were more senior secondary schools as compared to other education levels in the private category. The median of toilet ratio for boys was 28.9(Inter Quartile Range (IQR) = 20-73) in the Government and 23 (16-39) in the private schools in 2018(table-1). Table 2 depicted that one hundred fifty two (82%) schools were below bronze level during the baseline assessment but after intervention the schools in the same level reduced to 25(13%) i.e. 16(14%) government and 9(12%) private schools respectively which was found to be significant( p = 0.001). The proportion of schools acquiring silver accreditation increased from 9(5%) to 57 (31%) of schools (p = 0.001). Overall, the proportion of schools at the gold level increased from 1(0.5%) in 2016 to 71(38%) in 2018 which was found to be significant (p < 0.05).
Health profile of students from 8 higher accreditation schools (gold, silver) were compared in the lower ( below bronze) accreditation schools with 754 children from higher and 700 from lower accreditation levels were selected for further health assessment. The response rate in higher and lower accredited was 95.9% and 92.7% respectively.There was no significant difference between demographic characteristics of participants of higher and lower accredited schools. There was no difference as per gender among higher and lower accredited schools (p = 0.14). Among all the participants, majority of the students were in the age group 11-13 years i.e. 83% and 81% among government and private schools respectively.
Hygiene practices were better among students of higher accredited schools as compared to students of lower accredited schools (Table-4). More than 87% and 92% students from higher accredited schools reported that they washed their hands before eating and after toileting respectively as compared to lower accredited schools(p = 0.04).
Protective factors including peer support at school, parental or guardian supervision were found to significantly better among students of higher accredited schools (p = 0.005, p = 0.04). In relation to parents' or guardians' monitoring, 62% students of higher accredited schools reported approved parental control for observation on their free-time activities.
More than 63% students from higher accredited schools reported that they were taught to handle stress in healthy ways as compared to 55% children in lower accreditation level during school year (p = 0.003). The majority (66%) from lower accredited schools claimed they had serious injury happened to them in the past 12 months as compared to 62% higher accreditation level (p = 0.077).
About 20% students from higher accredited schools reported that parents or guardians drink alcohol as compared to 16% students from lower accredited schools(p = 0.05).
Students from lower accredited schools were more informed regarding HIV (36%) than those from higher accredited schools(46%). Knowledge regarding neatly looking person can be HIV infected was more in lower accredited schools children (30.42%) as compared to higher accredited school children (23.07%).It was found that students from lower accredited schools (30%) were more aware about HIV as compared to students from higher accredited schools (23%)(p = 0.001).

Discussion
School settings have long been recommended as an excellent health promoting settings. Studies have reported that evidence-based interventions in the school setting should be promoted as an important component for integrated programs, policies, and monitoring frameworks designed to reverse the childhood obesity in the region [5].Based on the multifaceted nature of the HPS, evaluation of the schools is a challenge due to broad concept [6].Hence the accreditation system, a practical tool to implement HPS was used in present study for assessment and classification of all government and private schools of Chandigarh city (2). The accreditation scheme has been implemented only in Thailand in the South East Asia region. In India, Chandigarh has become the first city to have undergone accreditation of all schools as HPS. Accreditation is a voluntary and continuous quality improvement process under different parameters. For self-improvement relevant school based interventions were provided in the current study. On achieving particular accreditation level, sustainability and ambition to move to the next level becomes the objective of a particular school.
Nevertheless, for sustainability, continuous active participation of the key stakeholders and commitment by school administration is required [7].
Study conducted in Hong Kong found that students in HPSs had a more positive health behavior profile as compared to those in non-HPS [8].A review evaluating nine studies of HPS emphasized that HPS has some influence on various domains of health for the school community In the current study, it was observed that knowledge and practices of personal hygiene of students studying in higher accredited schools were finer than students of lower accredited schools. A study reported that low awareness about personal hygiene were the key areas of concern and could be tackled by the active involvement of school teachers, bringing about improvement in personal hygiene of school children [12].Personal hygiene, mental health have been identified as priority areas for HPS .Hence students of higher accredited schools in the present study were more attentive to their personal hygiene and also taught to handle stress in schools.
Our study demonstrated that Shaala Siddhi has been implemented in government schools as compared to private schools. Shaala Siddhi is a national programme on school standards and evaluation[13]. It is a school self-evaluation process in a sequential manner and particularly domains1, 5,6, 7 i.e enabling resources of the school, school leadership and management, inclusion, health and safety, and productive community participation are related to HPS.
Our study showed that community partnership in decision-making and planning in the healthpromoting activities improved after one year of intervention in the current study. The HPS concept highlights community participation as integral to the success of health-promoting interventions.
Studies have reported that ownership, leadership, and collaboration are critical to improving school health. (14) If schools formally or informally create numerous interagency partnerships in the community students, families, and other community members can be engaged for participation in HPS.
Students from lower accredited schools were more informed about sexual behaviour module. Most of the lower accredited schools were in the periphery area of the Chandigarh city, considered at higher risk for the prevalence of HIV which are covered under targeted interventions (TI project). Hence the frequency of interventions on HIV might be more in these schools.
The higher accreditation schools were found better in hygiene practices, protective factors (peer support at school, parental or guardian supervision), handling stress, and less prone to injury as compared to lower accreditation level schools.
Hence, it is recommended that the assessment for accreditation should be carried out in all school settings in other parts of India and accreditation certification to be awarded. Hand holding support should be provided to schools for further improvement in accreditation levels. The assessment and classification of accreditation levels for establishing health promotion model in school settings is feasible and must be integrated into the school education system.

Conclusions
Health promoting schools interventions should be undertaken for enhancing accreditation levels. The study also concluded that there was a difference between various modules of health profile assessment like hygiene, mental health among higher and lower accredited schools. Hence accreditation of schools as HPS should be conducted on a periodic basis for further improvement and should be upscaled to the National level.

Ethics approval and consent to participate
Ethical permission for conduction of study was taken from the institutional ethics committee of Post Graduate Institute of Medical Education and Research.Written parental consent and the child's assent were obtained for health profile assessment

Availability of data and materials
The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests. This is to inform that Prof JS Thakur is an Editorial Board Member

Funding
The study has been conducted under the project funded by Indian Council of Medical Research.
Funding was provided for conducting the study, salaries of the project staff, travel and contingency grant. But no funding assistance was provided for publications of the manuscript.