Evaluation Index System of Shenzhen Health-Promoting Schools in China based on the SPO Model

doi:10.21203/rs.3.rs-2952763/v1

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Evaluation Index System of Shenzhen Health-Promoting Schools in China based on the SPO Model

https://doi.org/10.21203/rs.3.rs-2952763/v1

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Health-promoting schools is an important setting to publicize the concept, “Education and Health are an equal priority”, and it is an integral part of implementing the strategy of sanitation and health work jointly built and shared by the people. Based on the standards of Health-promoting schools management, this study constructed an index system of health-promoting schools in Shenzhen, China to meet the needs of management, evaluation, and development of Health-promoting schools in Shenzhen and promote the health of residents throughout the city by disseminating health concepts, knowledge, and skills to the students, their families, and their communities through the schools. By analyzing the existing literature on health-promoting schools and combining the characteristics of primary and secondary schools in Shenzhen, the index system was constructed in a preliminary way. After two rounds of the Delphi method to accept expert advice and using the analytic hierarchy process to calculate the weight of indicators at all levels in the evaluation system, the index system of Shenzhen Health-Promoting Schools was finally established. The authority coefficients of experts in the two rounds of consultation were 0.84 and 0.81, respectively, and the coefficients of concordance of experts’ importance of the index system were 0.24 and 0.25, respectively (P < 0.01). After the analytic hierarchy process test, the evaluation system consisting of 8 first-class indexes, 17 second-class indexes, and 64 third-class indexes of health-promoting schools in Shenzhen was finally determined. The system has a stable structure, coordinated expert advice, and a high degree of coherence.

Health-Promoting schools

evaluation index

SPO-model

Delphi method

analytic hierarchy process

Main contents and strengths:

1. The index developed for health-promoting schools is appropriate for the requirements of health promotion in the post-pandemic era (such as developing an online platform for school mental health education and family education; establishing an emergency system plan for public health emergencies).

2. It combines international and Chinese perspectives and serves as a reference for further refinement of the evaluation index system for health-promoting schools worldwide.

3. It provides a process for selecting and developing indicators for health-promoting schools through a mixed research approach (combining the method of Delphi consultation and analytic hierarchy process and the Donabedian’ SPO model).

Limitations:

The experts in the Delphi consultation have objective knowledge limitations and they assign subjectivity to indicators. When starting from professional judgment, the advantages are also limited by professional prejudice, which leads to a bias of results.
The analytic hierarchy process (AHP) is classified according to the maximum value of hierarchical weights, i.e. "maximum principle", and the correlation between hierarchical weights is not fully considered, so the evaluation results may have low resolution. At the same time, the AHP is to choose the better one from the alternatives, and the choice can only be from the original schemes, which cannot provide a new index increase scheme to solve the problem for this study.
The lack of empirical research is also a limitation of this study.The management of health-promoting schools begins with the building of indicators. The key link is implementation and inspection, and then improving and idealizing the health-promoting school construction system. If the implementation is not thorough, no matter how perfect the index system is, it is still meaningless. The health-promoting school evaluation indicators studied and formulated in this paper need to be put into the real scenario of schools in Shenzhen for inspection and optimization to achieve continuous updating and improvements.

Healthy schools are to provide students with a complete positive experience and knowledge and to promote students' healthy growth through the joint efforts of schools, parents, and all members of the communities, including setting up formal and informal health education courses, creating a healthy school environment, and providing appropriate health services. Managing a healthy school is a continuously improving process. It is a systematic project, which should be progressively improved on macro and micro levels.

Health-promoting schools is a new concept of school health advocated by the World Health Organization (WHO) around the world. It advocates that all the members i.e. teachers, students, leadership, and other administrative staff are all involved in Healthy School development, including formulating rules and regulations related to maintaining and promoting the health of teachers and students, providing complete and positive experience and knowledge structure by setting up formal and informal health courses, creating a safe and healthy school environment, providing appropriate health services, and mobilizing greater participation of families and communities in order to promote student and school faculty health.

At the end of the 20th century, scholars began to drive the implementation of establishing health-promoting schools and pushing them to develop into school networks, among which the European Network of Health-Promoting Schools (ENHPS) established in 1991, is the earliest school alliance. After that, similar organizations were established in Western Pacific, Latin America, South Africa, and Southeast Asian countries from 1995 to 1997.(Turunen et al. 1999) In the literature on the management of health-promoting schools, there are many studies on the implementation of health-promoting school policies, the process evaluation of intervention and the stage validation or tests, and also the standardized implementation of indicators in various countries and regions.

Inchley et al.(2007)evaluated the management experience of health-promoting schools in Scotland covering four aspects: ownership and authorization, leadership and management, cooperation, and integration, and believed that the success indicators related to the process should be determined as soon as possible.

Adamowitsch et al.(2017) evaluated the implementation activities of three Austrian health-promoting schools with multiple case methods. The results showed that health-promoting activities in Austria have not become the core work of schools like teaching in other disciplines, mainly because they are not within the scope of political authority. School planning and cooperation with surrounding communities and schools are very important for the management of health-promoting schools in Austria, but they have not received due attention.

Bonde et al.(2018)evaluated the implementation effect of "We Act" and Investigation, Vision, Action & Change (IVAC) in Danish primary schools through interviews and questionnaires, and confirmed that IVAC and HPS have limited functions in improving primary school students' eating habits, exercising activities, happiness, and social capital, and put forward that schools should be given sufficient preparation and development time in the HPS process evaluation.

In addition, the international community attaches importance to studying the intervention effect of schools in promoting the mental health of students and faculty members. Anwar-McHenry et al. (2016,2020) proposed three modules to build an Australian mental health-promoting school, namely: The curriculum developed by the Mental Health Association;Integrate "Take Action" into the social and natural environment of schools through school policies and guidelines, school management and marketing (including campaign branding and publicity)༛ Schools establish partnerships and collaborative services with local clubs, groups, and organizations that provide opportunities for mental health activities. Subsequently, taking teachers and students under the framework of "Western Australia Mental Health-Promoting Schools" as objects, through a one-year longitudinal study, it was confirmed that the Mentally Healthy Schools Framework (MHSF) intervention measures of "The Act-Belong-Commit Community-wide campaign" can improve students' mental health quality and effectively improve the happiness of faculty and staff.

German scholar Dadaczynski et al.(2021)studied the leaders who implemented the health-promoting school policy and found that three characteristics of whom would affect the implementation level of HPS in Germany, i.e., individual health literacy, attitude towards HPS, and professional self-efficacy. For the first time, it was proposed that health literacy should be integrated into the qualification and assessment of leaders (especially male leaders) in the HPS framework system. Then, 50,006 principals of public primary and secondary schools were studied in a cross-sectional study within 5 years. Two factors were obtained from 14 factors utilizing principal component analysis (PCA), which were HPS specific actions and HPS capacity building. It was clear that HPS provided intervention methods with health-promoting value in dealing with non-communicable diseases and their potential risks.

There are relatively few studies on the evaluation or assessment of the management of health-promoting schools in China, and the history of establishing health-promoting schools s in China began in the 1980s. After the concept of "health-promoting school" was put forward internationally, China began to design and declare health-promoting demonstration projects according to the project information of the WHO Western Pacific Working Group at the end of 1995. After being approved by the WHO's Western Pacific Region, Shanghai made many attempts to establish health-promoting schools, and Beijing also selected four schools as pilots. After that, Sichuan, Yunnan, Shandong, Zhejiang, and other regions also started pilot work. Shenzhen has made important achievements in establishing health-promoting schools. As of 2010, there are 64 health-promoting schools in Shenzhen, including 6 with gold medals, 15 with silver medals, and 43 with bronze medals. Hong Kong and Taiwan in China are also the earliest areas to encourage health-promoting schools (liu. 2019), and their promotion plans mainly focus on important elements such as school health policy, physical environment, social environment, personal healthy living ability, health services, and community relations.

The research in China focuses on theoretical management, current situation investigation, and policy research methods, and there are relatively few studies on the evaluation or assessment of the management of health-promoting schools. Qiu(2007)pointed out that the management of health-promoting schools needs the support of complete policies, strategies, and measures, including the implementation of manpower, materials, organizations, and funds, based on his own work experience as the in charge of health promotion in primary schools and the actual situation of health promotion in primary and secondary schools in Luohu District, Shenzhen. Pan (2015) took school physical education as the background and built an evaluation index system of school physical health-promoting ability, which was established by the Expert Investigation Method. From four aspects i.e. related personnel's ability, school organization ability, resource base, and physical health-promoting activities, it constituted 4 first-level evaluation indexes, 13 second-level indexes, and 48 third-level indexes to evaluate the effectiveness of school physical health promotion. Mei et al.(2017) investigated 315 Health-promoting schools in Ningbo and evaluated them with reference to the Assessment Standards for Health-promoting schools in Zhejiang Province. The results showed that the establishment of health-promoting schools in Ningbo had achieved initial success, but the allocation of health professionals and technical personnel and the content arrangement and pertinence of health education courses needed to be further improved. Yan et al. (2018)investigated the first batch of 170 primary and secondary schools for their health-promoting potential in various provinces of China and found that the weak links in the management were healthy environment, the quality of health education courses, and carrying out health activities that meet the needs of students' health problems. Shen et al. (2022)conducted a cross-sectional survey on the use of e-cigarettes among junior high school students in Xihu District’s Health-promoting school in Hangzhou city. The results showed that the attempted utilization rate of e-cigarettes among junior high school students used to be 6.02%, and the current utilization rate was 1.43%, which is lower than the average rate in China (the attempted utilization rate of tobacco among middle school students in China in 2021 was recorded to be 16.1%, and the current utilization rate is 3.5%). The ideal results were attributed to the comprehensive measures of health-promoting schools and smoke-free campuses in Zhejiang Province in recent years. Zhang (2022) combed the latest policy frameworks of the WHO and UNESCO for health-promoting schools, explained their theoretical and practical significance, and summarized and classified the fields, subjects, and contents of health-promoting schools.

Study design

In this study, the international research status and the latest research progress were arranged by literature analysis, and the evaluation indexes were collected and sorted out by comprehensive use of field investigation and expert argumentation to form an index database, and the evaluation indexes were preliminarily screened according to the principles of reliability, timeliness, systematisms, and hierarchy. After comprehensively ethical review, this study has been considered as no ethical issues by relevant ethics committee.See Fig. 1 for the detailed study designing and processing.

Study procedure

This study contains references from the essence of the existing health-promoting school index frameworks in advanced countries such as the United States, Australia, and Britain. It combines the latest domestic and foreign policies of health-promoting and management standards, and summarizes the practical experience of pioneering management in Beijing, Shanghai, and Hangzhou in China. The developed index of health-promoting schools is suitable for the national condition of China and the requirements of the post-pandemic era.

The Donabedian model for quality evaluation was utilized to build a coupling evaluation model and analysis framework of health-promoting schools in Shenzhen, composed of core indicators, common indicators, and development indicators with respect to three angles of structure, process, and outcome.

In this study, the Delphi method was used to screen the evaluation indexes and determine the evaluation index system, which was carried out for two rounds. According to the primary index, an Expert Consultation Form of Health-promoting schools Evaluation Index System was designed, 15 experts were invited to consult, and the questionnaires were sent by mail. To ensure the credibility and authority of the consultation results, this study selected front-line experts from universities, medical institutions, and industry associations, who have been engaged in related fields for a long time. The reliability of experts was determined by their positive coefficient, authority coefficient, and concentration of opinions, and the data were inputted and sorted by SPSS 26.0 and Excel software.

Analysis and rating

In this study, the analytic hierarchy process (AHP) was used to analyze all kinds of indicators and determine the weights of indicators at all levels. According to the selected indicators, the Questionnaire on Weight Assignment of Health-promoting schools Evaluation Indicators was formulated, for which 13 experts were invited to fill out. According to the calculation formula of the AHP, Excel was used for the calculation and analysis.

Consultation of experts

In this study, 15 experts from different fields were selected for consultation and all of them participated. The basic information of the experts involved in the consultation includes gender, age, major, research direction, work unit, post category (job title, professional title), educational background, etc.

The gender distribution was relatively balanced. There were 8 male and 7 female consulting experts. Among them, 7 experts were under the age of 35 years, 6 experts were 35–50 years old, and 2 experts were over 50 years old, having expertise in social medicine and health management, public health, psychology, preventive medicine, and hospital management. Moreover, 3 teaching staff members, 8 scientific research personnel, 4 medical and administrative personnel, and experts engaged in other positions were also included. 10 professionals who had worked in related fields for 5 ~ 10 years and 5 professionals who had worked for more than 10 years having certain practical experience were also included. All experts had obtained a master's degree or above, including 4 master’s and 11 doctorates or above. See Table 1 for the detailed basic information of experts.

Table 1

Basic information of consulting experts
Project	Category	Frequency	Proportion
Gender	Male	8	53.33%
	Female	7	46.67%
Age	Under 35 years old	7	46.67%
	35–50 years old	6	40.00%
	51–65 years old	2	13.33%
Educational background	Undergraduate	0	0.00%
	Master's degree	4	26.67%
	Doctorate and above	11	73.33%
Specialties	Public health	4	26.67%
	Social medicine and health management	5	33.33%
	Hospital management	3	20.00%
	Psychology	2	13.33%
	Preventive medicine	1	6.67%
Post category	Teaching staff	3	20.00%
	Scientific research personnel	8	53.33%
	Administrative staff	1	6.67%
	Medical personnel	1	6.67%
	Others	2	13.33%
Years of work	5–10 years	10	66.67%
	10–15 years	2	13.33%
	15 years and above	3	20.00%
Educational background	Undergraduate	0	0.00%
	Master's degree	4	26.67%
	Doctorate and above	11	73.33%

[insert -Table 1. Basic information of consulting experts - here]

Positive coefficient, authority coefficient, and coordination coefficient of experts

Expert positive coefficient: It is generally believed that when the recovery rate of the Delphi consultation questionnaire reaches more than 70%, it means that the experts are highly motivated. 15 consultation forms were issued in the first round of this expert consultation, all were collected and considered valid, and the effective recovery rate was 100%. In the second round, 15 questionnaires were sent out, 13 questionnaires were collected, and the effective recovery rate was 86.67%. The results demonstrated that the positive coefficient of Delphi experts was high, which also showed that 13 experts paid more attention to this study and their participation was serious.

Expert authority coefficient: When analyzing the consultation results, it is necessary to measure the authority degree of experts. In this study, the method of self-evaluation was adopted, and the authority degree of experts was notated by the expert authority coefficient (Cr), which was determined by the coefficient of determination (Ca) and experts’ familiarity (Cs) in this field. The expert authority coefficient (Cr) was calculated as Cr = (Ca + Cs)/2, 0 < Cr < 1. Through re-assignment of questionnaire scores, the judgment basis and authority degree of experts in this expert consultation were analyzed. The results showed that the expert authority coefficient (Cr) was above 0.8.

The mean value of the judgment basis coefficient (Ca) of each key index in the two rounds of consultation was between 0.91 and 0.89, respectively, which showed that the judgment basis had a high influence on experts. The average familiarity coefficient (Cs) was between 0.76 and 0.73 respectively, which indicated that the experts were familiar with the questions of this consultation. Table 2 shows that the average of the expert authority coefficient (Cr) of the two rounds of consultation was between 0.84 and 0.81, respectively, which can be considered a high degree of expert authority. Because the degree of authority of experts has a certain functional relationship with the prediction accuracy, it can be inferred that the accuracy of this study is also high.

Kendall's Coefficient of Concordance of expert opinion[15]: Kendall's Coefficient of Concordance reflects the consistency of the evaluation of each index among different experts and can also be used as an index to reflect the credibility of the expert consultation. In the first round of consultation of this study, the coefficient of concordance of expert opinions was 0.24, which is not high from the numerical point of view. It can be considered that some experts had different judgments about the importance of evaluation indicators, and the overall Coefficient of Concordance degree of opinions was low. The Coefficient of Concordance of expert opinion in the second round of consultation was 0.25, which was higher than that in the earlier round, which indicated that there was more consensus among experts on the importance of indicators. The P value of the χ2 test for the coefficient of concordance in the two rounds was < 0.05, which indicated that the confidence of results was higher under 95% confidence. See Table 2 for more details.

Table 2

Kendall's Coefficient of Concordance among experts in two rounds
	First round	Second round
Coordination coefficient W	0.24	0.25
χ 2 value	235.21	204.72
P value	0.00***	0.00***
Note: *** means p < 0.01.

Consensus of the two rounds of expert consultation

Before the Delphi consultation, a total of 8 first-level indicators (covering school health and health system, hardware facilities, related human resources, and financial security; Collaboration among students, staff, parents, and communities to provide health-promoting services and environment; The health literacy level of students and staff and health-promoting outcome standards), 16 second-level indicators, and 68 third-level indicators were initially illustrated.

According to the scores of the first round of experts, the indexes were screened according to the full score rate and coefficient of variation by using the boundary value method. After calculation, the selection criteria of indicators were determined as follows: the full score rate was > 0.65, and the coefficient of variation was < 0.20. Finally, 0 second-level indicators and 12 third-level indicators were deleted. 1 second-level index and 8 third-level indexes were added, while 1 second-level index and 9 third-level indexes were revised.

In the second round, the screening of indicators was still based on the score of experts and the boundary value method, while perfect score rate and coefficient of variation were used as the screening reference values. After calculation, the selection criteria of the index were determined: the full score rate was > 0.70, and the coefficient of variation was < 0.19. In the end, all the indicators of the second round were retained.

Weight Determination by the Analytic Hierarchy Process

The second round questionnaires were distributed to 15 experts, and 13 effectively replied. According to the scores and suggestions of the second round of recovery letters, the evaluation index system was revised. According to the importance of each index, a 1 ~ 9 scale table was used to compare the importance of each index in pairs, judgment matrices were established, and MATLAB software was used to calculate the maximum characteristic root and corresponding characteristic vector of each judgment matrix. After normalizing to get the weight of the corresponding index match to the upper level, the random consistency ratios (CR) of all the judgment matrices were < 0.10, meaning that they passed the random consistency test.

According to the above principles, the judgment matrices of three dimensions, first-class index, second-class index, and third-class index were constructed and the maximum characteristic root, corresponding characteristic vector, and consistency ratio of the index system in each matrix were obtained according to the calculation steps of analytic hierarchy process. The consistency ratios of the judgment matrices of the first, second, and third indicators of the three dimensions were 0 ~ 0.052, and all of them passed the consistency test (consistency ratio < 0.1). The detailed results are shown in the attachments.

Final Indicator System

Based on the scores of experts and the opinions about revision, the key evaluation index system was further revised and the final index system was determined. There are 3 dimensions in the evaluation index system of Health-promoting schools management, including 8 first-class indexes, 17 second-class indexes, and 64 third-class indexes. See Tables 3 and the attachments for details.

Table 3

Evaluation Index system of Health-promoting schools management in Shenzhen based on the SPO model
Classification index of the SPO model	First-class index	Weight	second-class index	Mean	SD	CV	Weight
Structure	A School Hygiene and Health System Management	0.311	A1 School hygiene and health-related legislation and regulations	4.769	0.330	0.069	0.344
	A School Hygiene and Health System Management	0.311	A2 School hygiene and health-related work plan	4.477	0.311	0.070	0.096
	B School Infrastructure and Hardware	0.493	B1 School health education equipment	4.538	0.419	0.092	0.182
	B School Infrastructure and Hardware	0.493	B2 Equipment for school life (medical treatment, environment, diet, sports)	4.709	0.211	0.045	0.240
	C Health-related human resources and funding guarantee	0.196	C1 School health (food, medical and logistics, management) related human resources allocation	4.519	0.297	0.066	0.138
Process	A School provides health-promoting services for students and faculty	0.297	A1 School organizes students and faculty members to have a free physical examination every year and establishes health records	4.423	0.449	0.102	0.118
			A2 School provides mental health-promoting services for all students and faculty members	4.462	0.519	0.116	0.173
			A3 School popularizes health knowledge to students and carries out health publicity and educational activities	3.923	0.572	0.146	0.039
			A4 School does a good job in preventing common diseases among students	4.654	0.376	0.081	0.245
			A5 School creates a caring environment conducive to physical and mental health for students with special difficulties (referring to special hardships physically, psychologically, in study, and in life)	4.423	0.494	0.112	0.118
	B School cooperates with parents to provide health-promoting services for students	0.163	B1 School and parents join hands to help students establish healthy behavior and habits, and create a unified, good growth environment for school	4.128	0.398	0.096	0.052
	C School and communities cooperate to create a good surrounding environment for students' health promotion	0.540	C1 School communicates with the community to obtain support and participation, and jointly create a clean, quiet, and safe environment around the school	4.462	0.519	0.116	0.173
		0.540	C2 School and community health centers establish a cooperative mechanism to provide medical and health services	4.231	0.599	0.142	0.082
Outcome	A The health literacy level of students and faculty members	0.667	A1 Students and faculty have basic health knowledge and ideas	4.319	0.538	0.125	0.269
			A2 Teaching and administrative staff hold the basic health promotion skills and can be paragons and supervisors of healthy behaviors	4.154	0.451	0.109	0.121
			A3 Students master health skills and develop healthy lifestyles and behaviors	4.431	0.315	0.071	0.420
	B School health-promoting results for students	0.333	B1 School does a good job in preventing common diseases among students	4.308	0.424	0.098	0.190

[insert -Table 3. Index system of Health-promoting schools in Shenzhen based on the SPO model - here]

Features and Strengths

Under the SPO framework, there are 8 first-class indicators, 17 second-class indicators, and 64 third-class indicators in the index system. The first-class indicators of structure quality dimension include school health and health system management, school infrastructure equipment, hygiene-related human resources, and financial guarantee. Langford, R et al. (2017) listed and analyzed the intervention outcomes of HPS in physical, psychological, family, community, and other factors around the world through a Cochrane systematic review. They put forward suggestions for future research on the WHO's health-promoting schools framework, and pointed out that the current health-promoting school framework lacks the content of adequate administrative support for health researchers to cooperate closely with educators to ensure the implementation of health-promoting schools and has not yet become an indicator for collecting quantitative data. In view of the national conditions of China, a formal information reporting system (epidemic reporting system) among health administrative departments and schools need to be set up, supplementing the indicators at the system level. The first-class indicators of the process quality dimension include schools providing health-promoting services for students and faculty, schools cooperating with parents to provide health-promoting services for students, and schools cooperating with communities to create a good surrounding environment for students' health promotion. The first-class indicators of outcome quality dimension include the health literacy level of students and faculty, and the health-promoting outcome of schools for the students. Using the analytic hierarchy process (AHP) to calculate the weight of the indicators of health-promoting school management, it is considered that the weight setting of all kinds and levels of indicators system obtained by calculation is reasonable. The top five indicators with characteristics of this study include " Establish an emergency system plan for public health emergencies and a notification system for infectious diseases." (0.076), "Set a psychological counseling room" (0.095), and "configuring related life first aid equipment (such as automatic external defibrillator (AED) with child mode, etc.) (0.076)". Under the background of the COVID-19 pandemic, the above-mentioned building indicators make up for the problems of health-promoting schools management in primary and secondary school health and health-related work planning, health equipment, focusing on public health emergencies, first-aid, and psychological counseling for teachers and students.

Among the top five indicators in the process dimension, “The school offers no less than four mental health education activity classes or special lectures for students' main psychological problems every year.” " The school conducts mental health-related knowledge and skills training for all teachers and requires teachers' mental health knowledge and skills training rate to be ≥ 95%", focus on mental health training and education for teachers and students; “The director of the Academic Affairs Office grasps the situation of students with difficulties in each class of grades”; “Teachers, especially class teachers, master the situation of students with difficulties in their classes” emphasizes teachers' understanding and concern for the financial difficulties of families. There are also related studies proving the significance of psychological indicators in Health-promoting schools. Kuyken et al. (2022) randomly selected 85 British primary and secondary schools and conducted a three-semester randomized controlled trial of school-based mindfulness training (SBMT) and teaching-as-usual (TAU), and proved that mindfulness training achieved positive effects to a certain degree on three mental health factors (depression risk, social emotional behavior function, and happiness). The related indicators of general psychological knowledge and skills training for schools and students in this study meet the requirements of international health-promoting schools in mental health, but the quantitative requirements of specific training times and knowledge and skills coverage need further empirical research.

Among the top five indicators in the outcome dimension, "the popularization rate of teachers' emergency rescue knowledge is ༞90%" reflects that the index system of this study supplements the allocation and requirements of teachers who fully master emergency skills in primary and secondary Health-promoting schools; "Controlled increase of students' poor eyesight detection rate", "Controlled increase of students' obesity detection rate and low weight detection rate (obesity BMI criteria are based on WST 586–2018 screening for overweightness and obesity of school-age children and adolescents)" reflect that this index system attaches importance to the high myopia rate and overweightness rate of primary and secondary school students at present, and is also an important index for Health-promoting schools management unanimously evaluated by experts. Bennett, L. and S. Burns (2020)and Elinder, L. S. et al. (2021)all believe that obesity in children and adolescents is a major public health problem. Under the framework of the World Health Organization Health-Promoting Schools, the results of most randomized controlled trials of HPS intervention on adolescent obesity show that the effect of obesity intervention on children under 12 years old is more significant in body mass index (BMI). Therefore, it is necessary to pay attention to the obesity rate of primary school students and measures to prevent obesity with empirical evidence.

Meanwhile, the research of L. S. et al. (2021)proves that it is necessary to test, evaluate, consult, and follow up on children's eyesight and hearing. In this study, the related indicators such as eyesight and obesity growth rate are in line with the international requirements for health-promoting schools to promote health and diet. However, it is also known that the research progress of adolescent obesity intervention under the framework of health-promoting schools in the world is ahead of that in China. China can continue to learn from the intervention and index evaluation methods and results, to speed up the index update, and strengthen the periodicity, comprehensiveness, and scientificity of data evaluation on adolescent diet and nutrition intervened by the relevant health-promoting schools.

Since 1917, the United States has attached importance to the "combination of medicine and education" to promote the work of school health promotion. In 2014, the American Association for Curriculum Development(ASCD) and the American Center for Disease Control and Prevention jointly put forward the "whole school, whole community, whole child, WSCC" model, which links students' health with comprehensive academic achievements and emphasizes the effective combination of health and education. It connects the school with the community, provides the community with the help of school health education, and integrates the school into the community. The dynamic improvement and development of health-promoting school indicators in Shenzhen need to refer to the global standards of health-promoting schools and implement them according to China's national conditions and Shenzhen’s characteristics, and constantly study that how can the implementation of health-promoting schools be embedded into the education system and schooling process.

Sawyer, S. M et al. (2021) concluded in "Make Every School a School for Health Promotion" published in the "Lancet-Children and Adolescents", that more and more international research evidence shows that the corona-virus pandemic has had a profound impact on schools. The overall physical and psychological health of students require not only emotional support provided by teachers in direct interaction, but it is also necessary for school leaders to reach institutional cooperation with the government, give sufficient funds and policy support, bridge the compatibility of special health intervention programs into the general curriculum system of schools, and use the strong political power of the government to promote the scale and sustainable implementation of health-promoting schools.

Suggestions for Implications

Since the outbreak of the COVID-19 pandemic in 2020, Shenzhen city prevailed with good prevention and control order. Under the normal environment of epidemic prevention and control, the activities in offline public places in Shenzhen were restricted and couldn't be carried out. Therefore, the working methods of health-promoting school management were adjusted accordingly. Under the condition that primary and secondary school students in Shenzhen studied online at home during the COVID-19 pandemic, their mental health and lifestyle changed. Before the epidemic, students spent most of their time in school, and their cognitive, social, and emotional personality characteristics and physical exercising behavior were closely related to the school environment. School is a main and unique psychological and physical health-promoting intervention place. However, during the epidemic, the interaction between students and schools became online, and the longest contact places for them were their homes and their communities. Therefore, the screening, identification, and intervention of students' physical and psychological problems during the epidemic needed the strong cooperation of schools, parents, and community personnel. Therefore, it is very significant to build an information interactive platform connecting schools, families, communities, and an online education resource system for health education. In the first-class indicators of the building process, "schools and parents cooperate to provide health-promoting services for students" and "schools and communities cooperate to create a good surrounding environment for students' health promotion". In particular, the establishment of online information platforms for families and schools is included in the index system (the third-class index "school provides information feedback platforms for parents, and communicate and implement health-promoting school work with parents through parents' committees"). In addition to the indicators built in this study, indicators for promoting mental health have been added separately from the three dimensions of the SPO model, including "setting up full-time and part-time psychological counselors (children's psychological counseling)", "school offers mental health education activity classes or special lectures, at least four times a year for students' main psychological problems", “The school conducts mental health-related knowledge and skills training for all teachers and requiring teachers' mental health knowledge and skills training rate ≥ 95%”, and “The testing rate of students' mental health ≥ 85%”. To sum up, this study puts forward the following three suggestions based on the existing research results:

1. Guided by policy support, the level of education should be comprehensively improved. Plans should be made for the classification of students at different stages, based on respecting the law of students' growth, starting from the diversified health needs of students, taking students' interests and hobbies as the leading factor, and carrying out health literacy intervention with the help of online and offline platforms, to promote the all-round development of students' health literacy skills and behaviors.

2. A linkage and cooperation mechanism of health education should be constructed to promote the participation of multiple subjects, which should be adhering to being student-centered, and the role of schools, families, and communities in the linkage and cooperation mechanism should be clarified. According to the different characteristics of students, the government should work flexibly and strive to build a linkage and cooperation mechanism among parents, teachers, and schools.

3. Various curriculum resources should be developed to promote the sustainable development of health education. Combining with the school-running resources, the school should create the curriculum and develop an exclusive curriculum resource package for different classes. An information interactive platform among schools, families, and communities should be built, promoting the management of online education resources system for health education, and strengthening the promotion of "Internet plus" in school mental health education and family education.

In this study, 8 first-class indexes, 17 second-class indexes, and 64 third-class indexes of Shenzhen Health-Promoting Schools were established under the SPO framework. From the weight results, the weight of the structure dimension (0.5936) was the highest, the weight of the process dimension (0.2493) was the second, and the weight of the outcome dimension (0.1571) ranked third. According to the weights, this study divided the indicators into core indicators, common indicators, and development indicators, to meet the requirements of different stages of health-promoting schools and strive to promote development through evaluation. As a matter of fact, most schools in China are public and education has a natural public welfare attribute. Under the purpose of implementing health promotion and other measures to improve school education, the most important thing is to get through and implement the system construction at the government level. On this basis, the school leadership should link up policies and make corresponding layouts in terms of health equipment, manpower, and funds. Furthermore, in the process, the government should closely focus on the standardized implementation of the big goal of "health promotion", obtain formulas for the evaluation indicators of outcomes, evaluate and publicize them openly and transparently, and achieve the ideal results of health-promoting schools construction.

To improve the practicability of the index system, this study developed a scoring table (see annex Table 1) and adopted the thousand-point system to evaluate and assign scores to the index. In the follow-up of this research work, we will demonstrate the practicality of the index system through an empirical study on the indicators of primary and secondary schools in Shenzhen.

The management of health-promoting schools begins with the building of indicators. The key link is implementation and inspection, and then improving and idealizing the health-promoting school construction system. If the implementation is not thorough, no matter how perfect the index system is, it is still meaningless. The health-promoting school construction indicators studied and formulated in this paper need to be put into the real scenario of schools in Shenzhen for inspection and optimization to achieve continuous updating and improvements.

Acknowledgements

We would like to express our gratitude to all the experts who provided us with their professional grading and advice during two rounds of Delphi method consultation.

Funding

This work was supported by the Shenzhen educational science 2020 annual planning project [Grant No. ybzz20034]; This work was also a project of Shenzhen Key Research Base of Humanities and Social Sciences (Social governance and Innovation Research Center of Tsinghua Shenzhen International Graduate School).

Availability of data and materials

Evaluation index system and the detailed results of AHP are available in the Additional file. Other information regarding data is available on reasonable request to the corresponding author: Dan Zhang.

Author Contributions

Dan Zhang designed the Delphi study and acquired funding. Jiaming Gu performed the literature review, analysed and synthesized the data and wrote the drat manuscript. Jiaming Gu and Dan Zhang was responsible for data analysis, data curation and project administration. Dan Zhang was in charge of project administration and supervision. Dan Zhang provided guidance on the two-round surveys. Dan Zhang commented and Sheng Wu edited the whole draft. Sheng Wu and Jiaming Gu critically revised the manuscript. All authors read and approved the final manuscript.

Ethical approval and consent to participate

Ethical approval for the study was obtained from the relevant ethics committee (Approval2023 No.F038, The Bioethics Committee, Tsinghua Shenzhen International Graduate School, China). All respondents provided written informed consent before participating in the study. All experts invited to participate in the Delphi consultation were informed that participation was voluntary, that their information would only be used for research purposes and was treated confidentially, and that there was no possibility of withdrawal at any stage of the study. All methods in this study were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing Interest

The authors do not have any competing interests to declare.

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Evaluation Index System of Shenzhen Health-Promoting Schools in China based on the SPO Model

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