1. Enhancing the science base for implementation in health promotion as an action strategy for sustainable development Discussant: Mark Dooris University of Central Lancashire Preston, UK

2. World Health Organisation Collaborating Centre Health Promotion Research Centre National University of Ireland Galway Ollscoil na hÉireann, Gaillimh Symposium on Enhancing the Science Base of Implementation in Health Promotion as an Action Strategy for Sustainable Development Researching the Implementation of Health Promotion Professor Margaret Barry

3. M. Barry Geneva 2010 Focus on Implementation Importance advances in developing the research base for health promotion policy and practice interventions over the last 20 years The generation and use of evidence in implementing and sustaining effective health interventions is under- researched Bridge the gap between research and practice translating from research to effective practice and from effective practice into research

4. M. Barry Geneva 2010 Expanding the Evidence Base Developing effective policy and programme interventions is only the first step in improving health and wellbeing –transferring to real world settings and sustaining them is a long term process necessary for maximising population impact Phases of the diffusion process –Initial design - pilot testing, efficacy and effectiveness trials –Dissemination – how well information about the intervention and its value is known –Adoption – whether the intervention is taken up –Implementation – how well the intervention is conducted –Sustainability – whether the intervention is maintained over time

5. M. Barry Geneva 2010 Expanding the Evidence Base Evaluation research to date has largely focused on initial design and intervention outcomes –paucity of data on the quality of implementation necessary for positive outcomes to be produced and sustained Emerging implementation science –science of adoption and implementation of evidence-based interventions that are scaled up –Type II translational research Expand the health promotion evidence base –guide the effective dissemination, adoption and sustainability of effective interventions across diverse cultural and economic settings

6. M. Barry Geneva 2010 Why Implementation Matters Determining how or why an intervention works –documenting actual implementation –assessing variability across change agents and settings Interpreting outcomes - distinguish between ineffective interventions and effective interventions that are poorly implemented Providing feedback for quality improvement Advance knowledge on best practice for effective intervention adoption, replication and sustainability (Durlak, 1998; Dane & Schneider, 1998; Mihalic et al., 2002; Domitrovich & Greenberg 2000; Durlak & DuPre, 2008)

7. M. Barry Geneva 2010 Factors Influencing Programme Implementation Characteristics of the intervention Characteristics of the implementer Delivery system – organisational capacity Support system – training and technical assistance The setting or organisational context in which the intervention is being implemented Characteristics of the intervention recipients/participants Complex interaction of these factors (Chen 1998; Fixsen et al., 2005; Greenberg et al., 2006; Greenhalgh et al, 2004)

8. M. Barry Geneva 2010 Implementation Principles The content and structure of the intervention –theory and evidence base –identify core components –quality of materials –quality and structure of technical support The process of planning, implementation and training systems Implementation support system - facilitatory and inhibitory factors in the local setting or context –readiness, ecological fit, organisational support etc. (Barry & Jenkins, 2007; Barry, Domitrovich and Lara, 2005)

9. M. Barry Geneva 2010 Sustainability Few interventions are sustained over time regardless of their impact (Rogers, 2003) Sustainability requires system transformation - organisation and structural change Limited research on the factors that predict sustainability Sustainability is a change process that is multifaceted, ongoing and cyclical Critical to fostering effective sustainable practice change

10. M. Barry Geneva 2010 The challenges Health promotion interventions - dynamic change in complex systems –change process at a whole system level –context, culture and organisational factors Process of change is not a linear process –multiple interdependent systems Limitations of the traditional research paradigm –complexity, rigour vs relevance, systems change Support for systems research –systems thinking paradigm

11. M. Barry Geneva 2010 The challenges Work bi-directionally to bridge science and practice –collaboration with practitioners in documenting implementation across the stages of planning, initial implementation, full scale delivery and sustainability –evidence may lag behind innovative practice Use of pluralistic methods –knowledge base of intervention participants and implementers –rules of evidence at each stage of evidence building Collaborative, systematic and systems-based approach to documenting the implementation of effective practice in different contexts Generate contextually sensitive practice-based evidence

12. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland The role of an implementation theory between impact research and process evaluation with regard to health promoting schools IUHPE Geneva 2010 Dr. Wolfgang Dür Director Ludwig Boltzmann Institute Health Promotion Research AUSTRIA, Vienna

13. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 15 The whole-school approach for health promoting schools 6 core- components healthy school policies material environment of schools social environment of schools individual health and skills connections to the community health services (c.f. St Leger et al., 2010) deficits of the WSA many separate and unlinked parts introduces complexity and causes confusion no organizational model of the school no clear intervention concept Many separate and unconnected parts: health promotion basic and quality management didactics theory of education

14. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 16 What is implementation? No definition in Health Promotion Glossary (Nutbeam et al. 2006) Seen as put a plan into action, realization, execution Naive, mechanistic plan-do-relation whole school approach, health promoting school approach Program Implemen- tation Evaluation Planning model What to do? How to do it? Do it! Check, what youve done!

15. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 17 Definition fulfil, perform, conduct, realize, concretize, specify, execute, put into action, do Implementation is the realization of an application, or execution of a plan, idea, model, design, specification, standard, algorithm, or policy. (Wikipedia) Implementation research investigates the gap between programs and their realization (ref. Hillmann 2007)

16. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 18 Change Theory (ref. Weiner et al. 2008: 293ff) theory of health theory of health promotion theory of health impact Program theory Theory of the organization empirical research Program adoption theory Implemen- tation theory Results Planning model Interventions can fail Reasons are: bad program bad program adoption bad planning difficulties in the implementation process! Needed is an implementation theory that explains the relation between the intervention and the intervened system Aspects of such a theory have implications for the conduction and evaluation of interventions Evaluation

17. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 19 The Vienna Health Impact Model organisation governance decision making processes organisation formal expectations structural premisses organisation core/support processes operative performance organisation output results individual self-awareness conscious & living processes individual dispositions mental & somatic premisses individual achievements quality of life individual re-/acting behaviour A B D C F E H G 2 3 1 5 6 7 8 9 10 11 12 13 14 4 social environment macro (e.g. politics, laws, acts, media, economy …) meso (e.g. communities, settings, networks …) micro (e.g. social support, personal Capitals: social, symbolic, cultural, economic …) material environment (e.g. building, facilities, hygiene, food, water, ergonomic workplace, sanitation, noise, air …)

18. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 20 The Vienna Organizational Health Impact Model organisation governance decision making processes organisation formal expectations structural premisses organisation core/support processes operative performance organisation output results individual self-awareness conscious & living processes individual dispositions mental & somatic premisses individual achievements quality of life individual re-/acting behaviour A B D C F E H G 2 3 1 5 6 7 8 9 10 11 12 13 14 4 social environment macro (e.g. politics, laws, acts, media, economy …) meso (e.g. communities, settings, networks …) micro (e.g. social support, personal Capitals: social, symbolic, cultural, economic …) material environment (e.g. building, facilities, hygiene, food, water, ergonomic workplace, sanitation, noise, air …)

19. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 21 Vienna Organizational Health Impact Model: unfolding the autopoiesis of organizations processes A structures B 1 1.As a social system, organizations consist of processes and structures 2.decision making processes build the basic autopoietic operation that leads to structural premisses communication structures programs (purposeful/conditional) person-specific, personnel decision making premisses 3.operative performance actions, interactions, occupa- pations, behaviors role-specific, etiquette-specific, individualized performance 2 4.results Performance is observed by the organization according to its goals (transfer action into information) organizational culture!! results 4 3 D C individual self-awareness conscious & living processes individual dispositions mental & somatic premisses individual achievements quality of life individual re-/acting behaviour F E H G 6 7 8 9 10 13 14 11 12 5 ORGANIZATION social environment macro (e.g. politics, laws, acts, media, economy …) meso (e.g. communities, settings, networks …) micro (e.g. social support, personal capitals: social, symbolic, cultural, economic …) material environment (e.g. building, facilities, hygiene, food, water, ergonomic workplace, sanitation, noise, air …)

20. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 22 Systemic organization theory and the PDCA-Cycle decision making processes = HP program adoption decision premises = HP program planning operative performance = HP implementation results = HP results Plan Do Check Act menue eating cooking recipe The systemic organization theory is compatible with the well known PDCA-cycle (Deming 1982) and can be seen as the unfolding of the organizations autopoiesis (Maturana & Varela 1990; restaurant analogy taken from Simon 2007)

21. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 23 organisation governance decision making Processes organisation formal expectations structural Premisses organisation core/support processes operative performance organisation output Results A B D C 2 3 1 4 Theory of the organization C-box represents all actions, behaviours, interactions performed on the grounds of the organization The chaos (Peters), the ocean (Luhmann) on which organizations thrive These are either role-specific (planned), supportive to role fulfilment (e.g. reproduction of workforce), or individual (smoking, chatting, mobbing…) Behaviours and interactions are self-referential and develop their own dynamic aside from organizational standards and defaults. By role-expectations, standards and eigen-dynamics the C-box can be described as the organizations real daily routines. Explanations to the C-Box

22. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 24 organisation governance decision making Processes HP agenda setting organisation formal expectations structural Premisses HP program adoption organisation core/support processes operative performance HP implementation organisation output Results HP results A B D C 2 3 1 4 Program theory Theory of the organization Program adoption theory Implemen- tation theory Planning model Like routine actions and interactions, interventions (innovations) follow social expectations and plans; as related to routines, they are either add-ons – competing for resources or add-ins – competing for attention, power, influence, survival in the system Success or failure of interventions (gap between planned and realized outcomes) is explained by a change or implementation theory Evaluation HP intervention in an organization

23. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 25 Common change theories in HP (1) Chen (1990, 2005; and following Weiss 1997) action model encompasses program adoption, planning model and structures (actors) change model (still) based on linear-causal relations: intervention-determinant- outcome evaluation as the feedback and regulation mechanism for the action model Implementation (change) theory implementation as a link between action and change model; seen as set of managerial methods to put into action no specific implementation theory explaining gaps between planned and realized outcome.

24. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 26 Program Theory (Chen, 1990, 2005) The model shows the influence of evaluation through feedback loops (Blank, Löwenbein, 2009) Main criticisms: Although program theory is based on the theory of open systems, Chen assumes causal relationships within the change model. He considers only evaluation feedback loops and not the ongoing dynamics of the system. The focus lies on the program.

25. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 27 Common change theories (2) Pawson & Tilley (1997): Realisitic Evaluation Acknowledge the conditions in the C-box success of implementation depends on such conditions Interventions must be adopted to the specific circumstances of a certain organization/system (= program specification) interventions cannot be standardized Evaluation is the feedback mechanism that guides program specification and improves the basic intervention concept Hidden assumption: There is a one best way to intervene for each system Context-mechanisms-outcome pattern configurations

26. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 28 Common change theories (3) Naaldenberg et al. (2008); Hummelbrunner (2008) intervention is depending on the context (see Pawson & Tilley) and a system of its own (also Pawson & Tilley) but a disturbance in the intervened system, causes resistence as well as new opportunities the problem is primarily not how to adapt interventions to systems, but how to make them robust and accepted interventions need commitment, good planning, persistence the intervened system must be prepared: readiness for change in the system (Weiner et al. 2008; Kotter 2006) the intervention system needs –robust methodologies (programme mechanisms, Hummelbrunner) –learning –partnerships

27. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 29 Intervention as a system in the system Going deeper into the relation between intervention system and intervened system: Basic paradox: intervention produces new structures/processes by using old ones (Simon 2007) intervention changes the system and the intervention at the same time De-paradoxication by deconstruction of old structures by new ones (Lewin (1997; and following Scharmer 2010): defreeze – change – refreeze Defreeze = deconstruction produces readiness for change Problem awareness, sense of urgency, Luhmann (2000): Change in organizations follows principles of evolution Variation (= intervention by trial and error) Selection (= reflection on variation and election of suitable) Retention/stabilization (= decision on structural premises regarding variation)

28. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 30 organisation governance decision making Processes HP agenda setting organisation formal expectations structural Premisses HP program adoption organisation core/support processes operative performance HP implementation organisation output Results HP results A B D C 2 3 1 4 Program theory Theory of the organization Program adoption produce variations Planning or action model Combines the two advices: (1) Adapt intervention to the system and (2) Strengthen the intervention against the system Implication for the intervention system: inspire, unleash several variations as add-ons and add-ins - C-box-evolution will decide upon what is useful, adequate, appropiate, meaningful … Implication for evaluation: support reflections on variations and their results that will lead to decisions pro or contra and transfer variations into routines. reflect on variations decide on variations establish variations Conclusion

29. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 31 Literature Chen, H.T. (1990, 2005): Theory-driven evaluation. Thousand Oaks, CA: Sage Publications. Hummelbrunner (2008) Response to paper Systems Thinking by D. Carbrera et al.: A tool for implementing DSRP in programme evaluation. Evaluation an Program Planning 31, 311-334. Kotter, J.P. (2007). Leading Change. Why Transformation Efforts Fail. Harvard Business Review, 2 Lewin, K. (1997) Resolving Social Conflicts: And, Field Theory in Social Science, American Psychological Association. Luhmann, N. (2000) Organisation und Entscheidung [Organisation and Decision]. Frankfurt am Main, Suhrkamp. Maturana, H., Varela, F. Der Baum der Erkenntnis. Die biologischen Wurzeln des Erkennens, Goldmann, 1990. Mintzberg, H. (1979) The structuring of organizations. A synthesis of the research. Prentice-Hall, New Jersey. Naaldenberg, J., Vaandrager, L. Koelen, M., Wagemakers, A.M., Saan, H., de Hoog, K. (2008) Elaborating on systems thinking in health promotion practice. Global Health Promotion; 16; 39. Noble, Charles H. 1999 : The Eclectic Roots of Strategy Implementation Research. Journal of Business Research. S. 120 Nutbeam, D. (2006): Health promotion glossary. Health Promotion international. Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: Sage. Simon F. (2007) Einführung in die systemische Organisationstheorie [Introduction to a systemic organization theory]. Carl-Auer Verlag, Heidelberg. St Leger, L., Young, I., Blanchard, C., Perry, M. (2010). Promoting health in schools – from evidence to action. Saint-Denis Cedex: IUHPE Scharmer U-Theory; Presencing Institute: http://www.presencing.com/presencing- theoryu/theoryu_downloads.shtml [25.5.2010] Weiner, B.W., Lewis, M.A, Linnan, L.A. (2008) Using organization theory to understand the determinants of effective implementation of worksite health promotion programs. Health Education Research, 24, 2, 292-305.

30. 20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 32 Contact: Dir. PD Dr. Wolfgang Dür, MA Ludwig Boltzmann Institute Health Promotion Research wolfgang.duer@lbihpr.lbg.ac.at

31. Questions for clarification

32. Creating and Operationalising a Science Base for Implementation Components of Health Promoting Schools Louise Rowling, Uni of Sydney, Australia Oddrun Samdal, Uni of Bergen, Norway IUHPE Geneve 2010

33. Introduction Previous focus of health promoting school (HPS) approach –Cross-sectoral collaboration between health and education –Production of guidelines articulating principles –Providing indicators for evaluation Focus of presentation – articulate science base of implementation of HPS to fill current gap –Develop a theoretical understanding of implementation components and their mechanisms

34. Adelman and Taylor, 2008

35. Underpinning conceptualisation Whole school community approach – system approach Organisational development and learning Multidisciplinary science base

36. Methodology Narrative synthesis of available English-language literature, 1995-2010, delineating implementation of HPS Key words: health promoting schools, implementation, comprehensive approach, whole school improvement/change, school health promotion. Implementation of pre-packaged programmes were excluded 7 sources were identified that described components of HPS implementation

37. The components 1) Preparing and planning for school development 2) Policy and institutional anchoring 3) Professional development and learning 4) Leadership and management practices 5) Relational and organisational support context 6) Student participation 7) Partnership and networking 8) Sustainability

38. 1. Preparing and planning for school development – what and why What –Readiness, commitment and alignment through stakeholder involvement –Systematic planning building on existing practices –Identify concrete policies, structures and practices for the complete implementation approach Why: Theoretical base –Programme/planning theory (Green & Kreuter, 2005) –Implementation theory (Barry, 2005; Elias et al., 2003 ) –Goal commitment and collective efficacy (Whitelaw, 2008) –Organisational change, school change and innovation ( Heward, Hutchins and Keleher, 2007; Hopkins and Jackson, 2003)

39. Preparing and planning for school development – how and why How –Preparing: gain commitment and anchor by identifying existing supportive structures and practices –Planning: ongoing participation through functioning representative committee; programme theory based planning model; Why: Theoretical and empirical base –Denman, 1999; Green and Kreuter, 2005; Hall and Hord, 2006; Inchley et al., 2007; Kellogg Foundation, 2004; Leithwood et al., 2007; McBride, 2000; Samdal et al., in press; Samdal, 2008; Spillane, 2006;

40. 2. Policy and institutional anchoring - what and why What –Intervention goals match with overall aims and visions of the school to stimulate ongoing alignment and commitment –Policy statement on HPS included in school policy plan Why: Theoretical base –Organisational change, school change and innovation (Heward, Hutchins and Keleher, 2007; Hopkins and Jackson, 2003) –Implementation theory (Barry, 2005; Elias et al., 2003 )

41. Policy and institutional anchoring – how and why How –Scaffold school development by anchoring intervention goals with overall aims and visions of the school through stakeholder involvement –Policy development and review by: Identifying existing supporting policies Formulating policy statement(s) and identifying strategy for actions and support Specifying financial, organisational and technical resources Theoretical and empirical base –Deschenes et al., 2003; Samdal, 2008

42. 3. Professional development and learning – what and why What –Professional development for key implementation staff –Ongoing professional learning for all staff at the school premises –Core base for building organisational capacity and individual motivation for change and ensures a whole school approach Why: Theoretical base –Organisational change, educational change (Heward, Hutchins and Keleher, 2007; Hopkins and Jackson, 2003) –Adult learning principles –Professional development (Easton, 2008; Fullan, 2008)

43. Professional development and learning – how and why How –Capacity building –Initial external PD of core team and executives for leadership, –Transfer of knowledge and competence to all staff by trained staff –School based professional learning for whole staff embedded in teachers work, Internal sharing of experiences and skill development through a range of PL strategies –External networking for executive staff and core team Why: Theoretical and empirical base –Daft, 1999; Fullan, 1992; 2008; Easton, 2008; Mason and Rowling 2005; Spillane, 2006; Tjomsland et al., 2009

44. 4. Leadership and management practices – what and why What –Balance of leadership and management –Leadership: visionary approach to stimulate readiness and motivation for change through feedback, encouragement and expectations –Management: Resource allocation, support structures and administration Why: Theoretical base –Social learning theory, social cognitive theory (Bandura, 1998) –Leadership theory (Fullan 2005, 2008)

45. Leadership and management practices – how and why How –Initiate anchoring of visions and aims with priorities –Share decision-making, negotiate directions, understand change processes, build relationships, build leadership at many levels –Role model and provide opportunities for the staff to share and reflect on knowledge and experience, give feedback and acknowledge contribution –Monitor implementation and guide redirections when needed –Celebrate progress and achievements –Ensure appropriate allocation of financial resources and supportive structures (time etc). Why: Theoretical and empirical base –Daft, 1999; Fullan 1992, 2005; Inchley et al., 2007; Larsen and Samdal, 2008; Samdal et al., in press; Rowling and Mason, 2007, Rowling 2009

46. 5. Relational and organisational support context – what and why What –Relational support: climate and culture –Organisational support: structures (including timetabling), physical environment and fiscal resources Stimulates motivation and change processes Why: Theoretical base –Social learning theory, social climate (Bandura, 1998) –Organisational capacity (Elias et al., 2003; Flaspohler et al., 2008; Hopkins and Jackson, 2003)

47. Relational and organisational support context – how and why How –Establish practices for interaction for all school community members –Nurture reflective behaviours –Pedagogic leadership to create caring environments in classrooms –Emphasis should be given to relational pedagogy –Scaffolding beneficial teaching schedules, class meetings, and grouping structures to allow time and opportunities for collaboration –Modify and create appropriate physical spaces/buildings –Supportive ongoing conditions for professional development and learning to build capacity. Why: Theoretical and empirical base –Boyd, MacNeil and Sullivan, 2006; Cole, 2008; Durlak and Dupre, 2008; Hall and Hord, 2006; Heward et al., 2007; Hoyle, 2007; MacNeil and Silcox, 2003; Samdal et al., in press

48. 6. Student participation – what and why What –Involvement of target group is basic principle of health promotion (empowerment) –Means and goal to maximize motivation for health and learning Why: Theoretical base –Self-determination theory, agency, initiative (Ryan and Deci, 2000) –School connectedness and civic engagement (Simovska and Bruun Jensen, 2009) –Relational pedagogy (Boyd,, Machnell, and Sullivan, 2006)

49. Student participation – how and why How –Facilitate student active decision-making in school life –Develop teachers skills to facilitate this action, putting aside their views and trusting in young persons perspectives and advice –Help young people learn they can make a difference to self and others –Create varying structures to facilitate students influence and participation and invite them to be represented in core team –Ask and listen to students perceptions of school needs for change and enable them to act on their ideas to address them in an inclusive and non judgemental manner Why: Theoretical and empirical base –AICAFMHA, 2008; Holdsworth and Blanchard, 2006; Jensen and Simovska, 2005;

50. 7. Partnership and networking – what and why What –Reciprocal partnerships: Stimulates mutual development and change Shared vision and decision-making Efficient use of resources and competence –Networking facilitates exchange of knowledge and raises consciousness that validates own practices Why: Theoretical base –Social learning theory, social climate (Bandura, 1998) –Organisational capacity (Elias et al., 2003; Flaspohler et al., 2008; Hopkins and Jackson, 2003)

51. Partnership and networking – how and why How –Develop partnerships and collaborative models requiring readiness, vision, leadership and time, and where appropriate establish contracts including commitment and responsibilities –Invite parents to contribute and to be represented in core team –Recognise the need for new multi-faceted and clearly defined roles for professionals –Lateral capacity building through links with other schools by shadowing and exchange of staff for sharing and learning from each other. Why: Theoretical and empirical base –Centre for School Mental Health, 2008; Deschesnes et al., 2003; Fullan, 2005; Inchley et al., 2007; Samdal et al., in press

52. 8. Sustainability – what and why What –The capacity of a system to engage in the complexities of continuous improvement (Fullan, 2005:IX) –Continued focus on institutionalisation –Needs to be addressed for each component Why: Theoretical base –Implementation theory (Barry, 2005; Elias et al., 2003; Flaspohler et al., 2008; Hopkins and Jackson, 2003)

53. Sustainability – how and why How –Implementing a project so that it becomes part of school priorities and practices –Monitor performance and evaluate progress, and where necessary, modify existing actions –Review needs assessment and continue to develop new priority areas –Continue to anchor initiative in written policies –Ongoing resource allocation –PD and PL for new staff, provide booster sessions for existing staff –Evaluate PL of staff, focussing on teacher and school administrator behaviour as indicators of system change Why: Theoretical and empirical base –Daft, 1999; Fullan, 1992, 2001, 2005; Firth et al., 2008; Inchley et al., 2007; Larsen and Samdal, 2008; Sabatier, 1997; Tjomsland et al., 2009; Tjomsland et al., 2009; Easton, 2008)

54. Conclusion Components are interdependent and provide balance of specificity and flexibility for whole school community change The components provide a basis to enhance the rigour of implementation and evaluation and monotoring for HPS Components need to be tested within school specific context and culture by practitioners and researchers

55. Questions for clarification

56. Discussion

57. Questions – Theoretical development - How do we measure systems change? How do we study/capture the process of change in such a way that it can be used to further knowledge in HP practice? What research skills are needed?

58. Questions – Practice development - Are the suggested implementation components sufficiently explicit and concrete to facilitate change in schools? –Are there core theoretical links missing? –Is there core practice knowledge missing? What practice skills are needed? –How can these be developed?