Promoting health in schools: Reviewing the evidence, setting the agenda

Systematic reviews are often the first step in a research project – after all, how can you know where you’re going if you don’t know where you’ve already been? As tedious as they can be to do when you’re raring to get your teeth into a new project, understanding what’s already been done (and what’s not been done yet) is a crucial part of the process.

Three systematic reviews on different aspects of school health promotion have recently been completed by researchers in Bristol, London and Exeter. Given how important the school context is to DECIPHer’s work, we wanted to bring together researchers, practitioners and policy-makers to hear the findings and discuss their implications. So last week, DECIPHer hosted a school health symposium with the morning dedicated to reviewing this evidence. Here I reflect on some of the key findings.

Photo of signposts at crossroads

By understanding what’s already been done in a field of research, systematic reviews help you figure out which direction your research should take.

Health Promoting Schools 
The day started with me presenting the results from our recently completed Cochrane review of the World Health Organization’s Health Promoting Schools framework, a whole-school approach to health improvement. This review of 67 rigorously-conducted cluster randomised trials found this approach can successfully improve a number of student health outcomes such as obesity, physical activity and fitness, fruit and vegetable intake, smoking and bullying.

Perhaps just as interesting, though, is what the review couldn’t tell us. Very few studies, for example, examined the impact of these interventions on academic outcomes – something which is of most interest to teachers! We also found very few studies from low- and middle-income countries using the Health Promoting Schools approach. With over 90% of the world’s children and young people living in these countries, this gap in the evidence seems hard to justify.

Another interesting trend we noticed was a tendency to focus on particular health topics with different age groups. The majority of interventions tackling physical activity and nutrition, for example, targeted primary school-aged children. While setting healthy habits early in life is important, we know obesity doesn’t go away in teenage years and rates of physical activity (particularly in girls) decline dramatically in adolescence. Perhaps we need more interventions targeting these issues in the teenage years?

The school environment 
Next, Farah Jamal from the University of East London presented findings from a review of the effects of school environment-based interventions on health. Farah’s fascinating talk presented data from qualitative studies, exploring the pathways through which the school environment might affect health.

One such pathway was the adoption of ‘tough’ identities by some groups of young people, especially those who feel educationally marginalised and unsafe. Engagement in risky behaviours such as substance use and violence can form an important point of bonding and security, helping students band with ‘tough’ peers to achieve ‘safety in numbers’. Farah also highlighted that young women become highly vulnerable in this context, where disrespect and violence towards women often becomes part of ‘tough’ male identity.

Other important themes included ‘unowned’ spaces within schools – unsupervised places that become hotspots for substance use and violence; the vicious cycle of poor relationships between staff and vulnerable young people; and disengaged students needing to ‘escape’ school, either physically by leaving school to go for a smoke, or mentally by heavy use of alcohol and/or drugs.

Picture of school lockers

Students may adopt ‘tough’ identities to keep safe and fit in at school

A realist perspective on implementation 
The final presentation of the morning was given by Mark Pearson from the University of Exeter, reporting on the findings from a realist review of the implementation of health promotion programmes in schools. By exploring the international literature, the review team developed four key theories to explain the factors and mechanisms that contribute to the success (or failure) of such initiatives in schools. These theories centred on:

  • preparation for implementation of an intervention;
  • initial implementation;
  • embedding interventions into routine practice;
  • and adaptation and evolution of programmes.

These four high-level theories were then tested and refined using data from empirical studies conducted in the UK. There was substantially less evidence relating to the latter two theories, reflecting the lack of interest in (and funding for) research into how best to sustain, embed and roll out successful programmes.

Key findings included: the importance of systematically planning interventions so that they fit in with the school’s existing responsibilities and activities; the strong support from governors and senior staff required to incorporate an intervention into a school; the time and motivation needed to embed any initiative within the school culture; and the importance for the sustainability of a programme of being able to identify which of its elements are ‘core’ (essential) and which are ‘peripheral’ (optional/adaptable).

A common agenda

While the three reviews focused on different elements of school health promotion, and used different methods to synthesise the data, what emerged was a complex but ultimately complementary vision of what health promotion in school could and should be like. These reviews now form a firm foundation on which we at DECIPHer can build to develop and evaluate school-based interventions to improve student health and wellbeing.

About the author: Dr. Beki Langford is a research associate at the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) , based at the University of Bristol. She tweets at @BekiLangford.

The Cochrane review on Health Promoting Schools can be freely accessed via the Cochrane Library here. A summary of its findings can also be found on the DECIPHer blog

The full report for the school environment review can be found here. The paper describing the qualitative findings from this review can be found here.

The protocol for the realist review of school health promotion is available here.

 Image source: Photo of lockers – Paradox 56, via Flickr.

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