Schools as social complex adaptive systems: A new way to understand the challenges of introducing the health promoting schools concept

Prevention of, and response to, sexual harassment at secondary school: A system map

BACKGROUND

Sexual harassment in secondary school is common but only recently acknowledged as a widespread problem in the United Kingdom. There is limited research on how schools respond to incidents of sexual harassment. The aim of this study was to understand how school systems shape the dynamics of disclosure, reporting and handling of sexual harassment in school (including behaviours, processes, norms), and to identify opportunities for effecting systems change.

METHODS

We used participatory systems mapping to elicit school stakeholders' perspectives on systems factors and their connections. Researchers built the map based on in-person workshops with students (n = 18) and staff (n = 4) from three schools in Scotland. Survey data (n = 638 students; n = 119 staff) was used to augment participant perspectives. The map was validated via three workshops (two online, one in-person) involving students and staff from seven schools.

RESULTS

The final map (causal loop diagram) represents a hypothesised system of 25 causally connected factors and three feedback loops shaping the disclosure, reporting and handling of sexual harassment. We grouped these factors into four interlinked themes: 1] Knowledge and confidence; 2] Trust in reporting system and processes; 3] Communication, confidentiality and safeguarding; and, 4] Prioritisation of sexual harassment.

CONCLUSIONS AND IMPLICATIONS

This study highlights the interconnectedness of factors shaping disclosure, reporting and handling of sexual harassment within secondary schools. The map surfaces key challenges for schools and provides a foundation for learning and discussions on where to focus efforts in future.

Enabling pupils to flourish: six evidence-based principles of whole-school wellbeing promotion

Schools have become increasingly important as health promotion settings, seeking to improve pupils' health and wellbeing through adopting a whole-school approach. A strong evidence-base highlights that focusing on the social, emotional and psychological aspects of pupils' wellbeing enables them to flourish, enjoy life and be better equipped to overcome challenges. However, it is acknowledged that further evidence is required regarding: (1) what happens in primary schools, (2) the impact of the English education system, (3) complexity and context, and (4) capturing children's voices. This article, therefore, addresses these gaps by asking the question: How do schools use whole-school wellbeing promotion to enable pupils to flourish? Taking an exploratory approach the study used a three-phase, mixed methods design to address the research problem by undertaking a systematic literature review, a secondary data analysis and a case study to capture multiple stakeholder voices including pupils. As appropriate for this research design, the findings from each phase were integrated into an overarching analysis which is presented in this article. Six broad principles formed consistent threads across the findings: (1) enabling children to flourish, (2) integrating wellbeing with key school goals, (3) promoting wellbeing and building capital, (4) building on virtuous cycles, (5) managing complexity and context, and (6) evaluating wellbeing promotion through listening to different voices. As well as presenting new knowledge addressing the identified research gaps, this study has demonstrated that schools can avoid 'reinventing the wheel' by adopting existing practices and resources and adapting them to their own setting. It is, therefore, hoped the six evidence-based principles of this study are equally transferable to schools within the English education system and more broadly. In addition, the paper highlights recognized challenges to staffing and resourcing and raises the question over whether schools receive sufficient funding to deliver the whole-school initiatives that government recommends. This article provides readers with an exploration of what has been achieved in schools and it is outside its scope to address specific issues about funding and other practical logistics for implementing whole-school wellbeing promotion, therefore further research is recommended.

Methodology for evaluation of complex school-based health promotion interventions

There is a need for careful examination of large volumes of collected (structured and unstructured) information related to school-based evaluation. There is also no published, comprehensive framework/s for evaluating complex interventions in Irish primary schools. The aim of this paper is to outline a methodology for process evaluation of an Irish primary school-based physical activity (PA) and nutrition intervention. Evaluation followed the three themes outlined by the British Medical Research Council: implementation, context, and mechanism of impact that we further divided into six dimensions. Methodological tools included questionnaires, PA logs, reflective journals, write and draw, and semi-structured interviews. We triangulated findings across these multiple tools to assess each dimension. We designed a unique framework to enable comparisons and offer researchers a template for evaluating complex health promotion interventions in primary schools. We present a methodology for evaluating a complex school-based health promotion intervention. The framework we propose integrates process and outcome data. It aims to enhance future result interpretation and facilitate informed comparisons among intervention schools.

Schools' readiness for child sexual abuse prevention education: Preliminary scale development using a Delphi method

BACKGROUND

This study employed a Delphi method with a panel of experts to collaboratively design a new instrument to assess schools' readiness for school-based child sexual abuse prevention education.

METHODS

An initial item pool was generated based on a review of existing empirical research and theoretical models. We invited researchers and stakeholders in the field of child sexual abuse prevention as experts to participate in a two-round online Delphi study in which they rated item importance and clarity, contributed their views on superfluous and/or missing items, gave rephrasing suggestions, and re-appraised revised items. Following the Delphi study, the instrument was pilot tested with a convenience sample of school staff.

RESULTS

The initial item pool comprised 81 items in five construct sub-scales congruent with Wiener's Organizational Readiness for Change theory: contextual factors, informational assessment, change valence, change commitment, and change efficacy. In the Delphi study, 24 experts participated in round 1, and 13 participated in round 2. Based on Delphi study responses, the instrument was reduced to 56 items in the five construct subscales: contextual factors (28 items), informational assessment (13 items), change valence (6 items), change commitment (3 items), and change efficacy (6 items). The Schools' Readiness for Child Sexual Abuse Prevention Education (SR-CSAPE) was successfully pilot tested with school staff (n = 19) and minor changes to demographic items were incorporated.

CONCLUSIONS

Informed by experts, the Schools' Readiness for Child Sexual Abuse Prevention Education (SR-CSAPE) is a newly-developed 56-item scale that identifies key organizational dimensions to schools' preparedness for CSA prevention education. Psychometric properties of the scale must be determined in future research.

The Role of School Health Promotion in Students' Dietary Intake during School Hours: A Qualitative Comparative Analysis

Many children in the Netherlands do not adhere to dietary guidelines. Therefore, the Healthy School (HS) program stimulates healthier dietary intake of students through schools. However, evaluating the effectiveness of school health promotion in improving dietary intake is challenging due to the influence of contextual factors. Qualitative Comparative Analysis (QCA) considers these contextual factors. Therefore, we performed a QCA to examine which (combinations of) contextual factors contribute to the healthier dietary intake of students during school hours in primary schools (approximate age range children 4-12 years) and secondary schools (age range 12-18 years) when implementing the HS program for nutrition. Data were collected mainly through interviewing school staff and a school-level questionnaire in fifteen primary schools and twelve secondary schools. We included five factors for primary schools: implementation of the HS program for nutrition, degree of implementation, socioeconomic status, parental support, and student support. For secondary schools, we included school environment instead of parental and student support. For primary schools, the best results were obtained if the HS program for nutrition was implemented in high socioeconomic status schools with a combination of high implementation, parental support, and student support. Findings indicate that if secondary schools have an impeding environment and low socioeconomic status, implementation of the HS program for nutrition can result in healthier dietary intake.

Implementation processes of social network interventions for physical activity and sedentary behavior among children and adolescents: a scoping review

BACKGROUND

The characteristics of the implementation process of interventions are essential for bridging the gap between research and practice. This scoping review aims to identify the implementation process of social network interventions (SNI) to address physical activity and sedentary behaviors in children and adolescents.

METHODS

The scoping review was conducted adhering to the established guidelines. The search was carried out in the ERIC, EBSCO, EMBASE, SCOPUS, and Lilacs databases in April 2023. Social network intervention studies in children and adolescents were included, addressing physical activity or sedentary behaviors. Replicability (TIDieR), applicability (PRECIS-2), and generalizability (RE-AIM) were the explored components of the implementation process. Each component was quantitatively and separately analyzed. Then, a qualitative integration was carried out using a narrative method.

RESULTS

Most SNI were theoretically framed on the self-determination theory, used social influence as a social mechanism, and used the individual typology of network intervention. Overall, SNI had strong replicability, tended to be pragmatic, and three RE-AIM domains (reach, adoption (staff), and implementation) showed an acceptable level of the generalizability of findings.

CONCLUSIONS

The analyzed SNI for physical activity and sedentary behaviors in adolescents tended to be reported with high replicability and were conducted pragmatically, i.e., with very similar conditions to real settings. The RE-AIM domains of reach, adoption (staff), and implementation support the generalizability of SNI. Some domains of the principles of implementation strategies of SNI had acceptable external validity (actor, action targets, temporality, dose, and theoretical justification).

A Qualitative Study of Preschool Children's Perspectives on an Oral Health Promotion Program in New South Wales, Australia

In Australia, dental caries are observed in almost half of children starting school. Oral health promotion programs are being implemented in early childhood education and care (ECEC) settings to promote oral health. This study examined children's perceptions of one such program, the Bright Smiles Bright Futures (BSBF) program in ECEC settings in New South Wales, Australia. Data were collected using focus group discussions from 15 children aged 3-5 years, transcribed verbatim, and analysed through inductive thematic analysis. Three themes were identified as follows: (i) oral health knowledge of children, (ii) oral hygiene practices routine and skills development, and (iii) evaluation of the oral health promotion kit and opportunities for improvement. Children's perspectives highlight the BSBF program's success in communicating key messages to promote oral health. The integration of family-centric approaches, acknowledgement of children's preferences, and the use of interactive tools collectively enhance the overall effectiveness of the oral health promotion program.

School-based interventions TO Prevent Dating and Relationship Violence and Gender-Based Violence: STOP-DRV-GBV systematic review

Background

Schools have a duty of care to prevent violence between students but a significant amount of dating and relationship violence and gender-based violence occurs in schools. These are important public health issues with important longitudinal consequences for young people.

Objectives

To understand functioning and effectiveness of school-based interventions for the prevention of dating and relationship violence and gender-based violence.

Review methods

We undertook a mixed-methods systematic review to synthesise different types of evidence relating to school-based interventions for the prevention of dating and relationship violence and gender-based violence to understand if, how and in what ways these interventions are effective. We searched 21 databases and 2 trial registers and undertook forwards and backwards citation chasing, author contact and other supplementary search methods. Searches identified all literature published to June 2021. All screening was undertaken in duplicate and independently, and we quality appraised all included studies.

Results

We included 247 reports (68 outcome evaluations, 137 process evaluations). Synthesis of intervention components produced an intervention typology: single-component, curricular, multicomponent, and multilevel programmes. Synthesis of intervention theories suggested that interventions aiming to increase students' sense of school belonging and sense of safety in the school building could encourage increased learning of prosocial skills and increased prosocial peer norms, and so potentially reducing dating and relationship violence and gender-based violence. Synthesis of factors affecting delivery highlighted school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important. Meta-analysis found stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration, and some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. Impacts on knowledge and attitudes were primarily short-term. Network meta-analysis did not suggest superiority of any intervention type. Moderation evidence suggested interventions reduced dating and relationship violence perpetration in boys more than girls, but reduced gender-based violence perpetration more in girls. Metaregression by intervention component did not explain heterogeneity in effectiveness, but qualitative comparative analysis suggested that reducing perpetration was important to reducing victimisation, and that perpetration could be reduced via focus on interpersonal skills, guided practice and (for gender-based violence) implementation of social structural components.

Limitations

Despite an exhaustive search, trials may have been missed and risk of publication bias was high for several analyses.

Conclusions

This is the most comprehensive systematic review of school-based interventions for dating and relationship violence and gender-based violence to date. It is clear that the prevention of dating and relationship violence and gender-based violence in schools will require longer-term investment to show benefit.

Future work

Future research is needed to understand why intervention effectiveness appears stronger for dating and relationship violence than gender-based violence.

Study registration

The study is registered as PROSPERO CRD42020190463.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR130144) and is published in full in Public Health Research; Vol. 12, No. 3. See the NIHR Funding and Awards website for further award information.

Exploring settings as social complex adaptive systems in setting-based health research: a scoping review

Since launching health health-promoting settings approach to health by WHO, valuable progress has happened in implementing its holistic concepts in settings such as cities, schools, workplaces, hospitals and healthcare services. However, significant knowledge-intention-success gaps still exist in creating sustainable health-promoting changes in settings. The complexity of the task of bridging this gap has contributed to the call for a complexity-informed paradigm shift to health as well as settings, followed by increasing consultation of relevant complexity theories, frameworks and tools in health research. This paper provides a critical scoping review of the application of complex adaptive system (CAS) theory in settings-based health promotion research. We included 14 papers, mostly qualitative studies, reporting on planning or implementation of change initiatives, less on its evaluation. CAS theory application was often incomplete thereby reducing the potential benefit of using this lens to understand change management. We suggest some recommendations how to comprehensively apply the CAS theory in setting-based health research and to report on all CAS characteristics to enhance the understanding of settings as adaptive health-promoting settings.

Optimising a co-production framework for developing public health interventions: application and testing of school-based Research Action Groups

Existing frameworks for developing public health interventions have limited guidance for researchers on how to work with stakeholders to co-produce context-specific interventions. To address this, a promising framework for the co-production of public health interventions was developed through a previous review of school-based co-production. The present study aimed to optimise this co-production framework through applying and testing it in real-world secondary school contexts. Within schools, Research Action Groups (RAGs) were established with multiple school stakeholders supported by an external facilitator to use school data to produce school-specific mental health and wellbeing interventions. A mixed method process evaluation of two contextually diverse case study secondary schools in the UK was used to optimise the co-production framework. The process evaluation sought the views of those involved (students, school staff, school Senior Management Team (SMT) members, and the external co-production facilitator/researcher) on the co-production functions they were involved in so they could be modified, if needed. Data collected for the process evaluation during co-production were a researcher diary (n = 45 entries), and observations of student photography (n = 21) and RAG meetings (n = 8). Post co-production, interviews, and surveys with RAG students (n = 18) and staff (n = 8), and two school-specific SMT focus groups (n = 10) were conducted. The study identified four recommendations to optimise and integrate co-production into real world practice. They include the need to: assess schools for their readiness to undertake co-production; more effectively communicate the necessity to have stakeholders from the whole system involved; work with SMTs throughout co-production functions; involve stakeholders outside the school to support producing solutions to change school mental health and wellbeing priorities. The framework is intended to be used by researchers to integrate stakeholders into a shared decision-making process to develop interventions that meet the needs and contexts of individual schools. It could be transferred to other settings to support the development of public health interventions for other health areas, and populations. Further evaluation to test its use in other settings is needed.

Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study

Implementing comprehensive health promotion programs in the school setting can be challenging, as schools can be considered complex adaptive systems. As a first step towards understanding what works in improving implementation for which schools and under which conditions, this study aimed to examine the degree of implementation of health promoting school (HPS) programs, in terms of five dimensions of fidelity (adherence, dose, participant responsiveness, quality of delivery and program differentiation), and the dimensions of adaptation and integration. The HPS Implementation Questionnaire was distributed among ± 2400 primary, secondary, secondary vocational and special needs schools in the Netherlands. Employees of 535 schools (22.3%) filled out the questionnaire. Data were analysed by descriptive statistics and ANOVA tests. The average degree of implementation was 2.55 (SD = 0.58, range = 0.68-3.90; scaled 0-4). The lowest scores were achieved for participant responsiveness and adherence, and the highest for integration and adaptation. Schools that identified as HPS reported significantly higher overall degree of implementation, adherence, dose, participant responsiveness, program differentiation and adaptation than schools that didn't. Primary schools achieved a significantly higher degree of implementation, dose, participant responsiveness, quality of delivery and integration than other school types. In conclusion, many schools work on student health and well-being to some extent, but the vast majority have much room for improvement. Higher implementation scores for schools that identified as HPS underline the value of HPS programs. A broader perspective on health and more insight into conditions for effectiveness and implementation in secondary and secondary vocational schools are needed.

Same, Same but Different: Comparing Program Fidelity at Early Versus Late Adopters of a Successful Long-Term School-Based Physical Activity Intervention

Schools have been identified as a promising setting for promoting physical activity (PA). Yet, to realize changes at the population level, successful school-based PA programs need to go to scale. The Svendborgproject is an effective school-based program promoting additional physical education (PE) lessons. The aim of this study is to determine program fidelity across different school groups, representing early and late adopters of the Svendborgproject, and how these are adapting the intervention. Three different school groups were identified, covering the original intervention schools and two groups of late adopters consisting of four former control schools, and five normal schools without any previous connection to the program. A PE teacher questionnaire (n = 122) was used to determine school fidelity. The results show that, while the original intervention schools have implemented the program with the highest fidelity, all schools have implemented the program with medium to high fidelity. It is suggested that having front-runner schools achieving early success with the program both strengthens political project support and provides strategies to back late adopters' implementation of the program. Furthermore, results from the current study suggest that continual promotion of the program by school heads is less important if support is established at the structural and organizational macro level. Finally, we highlight the importance of scaling up organizational capacity when scaling up program reach to assure a workable balance between fidelity and improving the fit to specific contexts.

Mapping communities as complex adaptive systems: A study of the response to violence against women by communities in Samoa

This paper explores the concept of communities as complex adaptive systems in the context of violence against women (VAW) prevention. Using thematic network analysis on data from 80 semi-structured interviews with community members in Samoa, we found that communities exhibit many properties of complex adaptive systems. Within nested systems, diverse and dynamic agents interact based on their knowledge and attitudes, which changes over time, leading to emergent and unpredictable outcomes. The functioning of communities and their response to VAW is a product of non-linear and emerging relationships and interactions between systems components at the community level. The approach we propose for conceptualising communities as complex adaptive systems provides a structured method for designing and evaluating community-based interventions that are grounded in the local context and existing resources. With in-depth knowledge of how a community works, interventions can be better equipped to address wicked problems such as VAW.

Unpacking School-Based Child Sexual Abuse Prevention Programs: A Realist Review

Background: Existing efforts to understand school-based child sexual abuse (CSA) prevention programs mainly focus on the effectiveness of these programs in increasing participants' CSA knowledge and self-protective skills. There are currently no reviews addressing the underpinning pathways leading to these outcomes. In order to increase our understanding about the underpinning causal and contextual factors and inform the further development of school-based CSA prevention programs, a realist review was conducted to synthesize existing evidence from a broad range of data. Methods: An iterative search of electronic databases and grey literature was conducted, supplemented with citation tracking to locate relevant literature. For quantitative evidence, we considered evaluation studies that focused on students aged 5-18 years, who were enrolled in primary or secondary schools; for other types/formats of studies/documents, no population restrictions were applied. We included school-based CSA prevention programs that focused on improving knowledge of CSA or self-protective skills. Outcomes of interest included knowledge of CSA or self-protective skills. We did not apply methodological filters in terms of the types of studies to be included. Thematic content analysis was conducted to synthesize data. Results: Sixty-two studies were included. Five themes and five overarching Context-Strategy-Mechanism-Outcome configurations (CSMOs) that contributed to the success of school-based CSA interventions were identified, including tailoring programs to participants' cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information and application of the 'train-the-trainer' model. Implications: Findings from this realist review provide insights into the underlying program theory of school-based CSA prevention programs, which can aid in the development and implementation of these programs in the future.

Increasing community capacity to improve the implementation of Health Promoting Schools: barriers and facilitators from the FLASH intervention

Building community capacity is important for the successful implementation of a Health Promoting School. To identify how capacity building can be encouraged in secondary schools, four schools engaged in the Fit Lifestyle at School and at Home (FLASH) intervention for 3 years. This study explores barriers and facilitators that school personnel, parents and pupils experienced in the capacity-building process. Thirty-one stakeholders were interviewed. Transcripts were analysed thematically based on the five actions of the intervention: (i) appoint a Healthy School coordinator and build a team, (ii) determine ambitions, (iii) design and (iv) implement the action plan and (v) evaluate and improve. The time and support allocated to coordinators helped them evolve their role from executors of health-promotion activities to coordinators, instigators and gatekeepers of the implementation process. Participatory tools helped identify shared values among stakeholders to determine context-specific ambitions and leverage points for interventions. Coordinators indicated that they lacked the skills and authority to engage pupils and parents and to reach the broader community. Coordinators struggled with translating promising ideas into action plans of coherent and mutually supportive activities and embedding them into policy. Strong leadership of Healthy School coordinators, who focus on the capacity-building process and foster collaborative relationships, is essential to build community capacity. In this process, more guidance is needed on how to involve the broader community in various phases. Furthermore, coordinators can benefit from professional development to align jointly designed activities into a comprehensive action plan embedded into Healthy School policies.

"We want it to be a culture": children and young people's perceptions of what underpins and undermines education-based wellbeing provision

BACKGROUND

Provision that aims to promote the social, emotional, and mental wellbeing of children and young people (including their mental health) is increasingly implemented in education settings. As researchers, policymakers, and practitioners explore the complexities of promotion and prevention provision in practice, it is critical that we include and amplify children and young people's perspectives. In the current study, we explore children and young people's perceptions of the values, conditions, and foundations that underpin effective social, emotional, and mental wellbeing provision.

METHODS

We engaged in remote focus groups with 49 children and young people aged 6-17 years across diverse settings and backgrounds, using a storybook in which participants constructed wellbeing provision for a fictional setting.

ANALYSIS

Using reflexive thematic analysis, we constructed six main themes presenting participants' perceptions: (1) recognising and facilitating the setting as a caring social community; (2) enabling wellbeing to be a central setting priority; (3) facilitating strong relationships with staff who understand and care about wellbeing; (4) engaging children and young people as active partners; (5) adapting to collective and individual needs; and (6) being discreet and sensitive to vulnerability.

CONCLUSIONS

Our analysis presents a vision from children and young people of an integrated systems approach to wellbeing provision, with a relational, participatory culture in which wellbeing and student needs are prioritised. However, our participants identified a range of tensions that risk undermining efforts to promote wellbeing. Achieving children and young people's vision for an integrated culture of wellbeing will require critical reflection and change to address the current challenges faced by education settings, systems, and staff.

Evolution of 'whole institution' approaches to improving health in tertiary education settings: a critical scoping review

In recent decades, 'whole school' approaches to improving health have gained traction, based on settings-based health promotion understandings which view a setting, its actors and processes as an integrated 'whole' system with multiple intervention opportunities. Much less is known about 'whole institution' approaches to improving health in tertiary education settings. We conducted a scoping review to describe both empirical and non-empirical (e.g. websites) publications relating to 'whole settings', 'complex systems' and 'participatory'/'action' approaches to improving the health of students and staff within tertiary education settings. English-language publications were identified by searching five academic and four grey literature databases and via the reference lists of studies read for eligibility. We identified 101 publications with marked UK overrepresentation. Since the 1970s, publications have increased, spanning a gradual shift in focus from 'aspirational' to 'conceptual' to 'evaluative'. Terminology is geographically siloed (e.g., 'healthy university' (UK), 'healthy campus' (USA)). Publications tend to focus on 'health' generally rather than specific health dimensions (e.g. diet). Policies, arguably crucial for cascading systemic change, were not the most frequently implemented intervention elements. We conclude that, despite the field's evolution, key questions (e.g., insights into who needs to do what, with whom, where and when; or efficacy) remain unanswered.

Measuring Implementation of Health Promoting School (HPS) Programs: Development and Psychometric Evaluation of the HPS Implementation Questionnaire

BACKGROUND

Implementation of Health Promoting School (HPS) programs can be challenging due to the dynamic school context. Navigating between program fidelity and adaptation, as well as integrating the program, is essential for successful implementation, and consequently, for program effects. As part of an evaluation study in the Netherlands, this study aimed to develop a measurement instrument that differentiates schools according to fidelity, adaptation, and integration of HPS implementation.

METHODS

This study presents the development and psychometric evaluation of the 28-item HPS Implementation Questionnaire, covering 7 dimensions: adherence, dose, participant responsiveness, quality of delivery, program differentiation, adaptation, and integration. The questionnaire, to be filled out by school employees, was developed for primary, secondary, secondary vocational, and special needs education, in close collaboration with experts (n = 54) in school health promotion.

RESULTS

Semi-structured interviews aimed at dimension clarification resulted in a list of 58 items. Items were revised, combined, and/or removed based on quantitative and qualitative feedback by the evaluation study's Community of Practice, 2-round expert consultation, and pre-tests. Psychometric evaluation (n = 535 schools), consisting of calculating Cronbach's α and confirmatory factor analysis (CFA), confirmed internal consistency (α > .72) and the 7-dimension framework.

CONCLUSION

The brief yet comprehensive HPS Implementation Questionnaire offers possibilities for research into HPS implementation in various educational sectors and contexts, as well as self-monitoring by individual schools. This study provides first evidence for internal consistency and validity of the questionnaire.

The Impact of Periodic Formative Assessments on Learning Through the Lens of the Complex Adaptive System and Social Sustainability Principles

PURPOSE

Medical institutions in India have employed different periodic formative assessment (FA) methods with variable impact. The formative evaluation must incorporate feedback to improve learning. Formative assessment has helped inexperienced students apprehend their weaknesses, make choices, prepare for summative exams, and allow teachers to identify regions wherein students may also need aid. This study attempts to quantify the impact of the weekly, monthly, and semester formative assessments and view it retrospectively through the lens of complex adaptive systems and social sustainability principles.

METHODS

We used a post-exam survey and statistical analysis to compare the students' performance between the timely periodic formative assessments in a competency-based curriculum. The cohort consisted of 2018 (semester), 2019 (weekly), and 2020 (monthly) first-year medical students. Cronbach alpha, spearman's correlation coefficient, descriptive statistics, and repeated measure analysis of variance were used to explore the reliability and relationship between formative assessment and summative scores of each cohort and find any significant difference. The authors also analyzed the accordance between the FA exam performance and students' perceptions, deduced broad themes, and discussed the appropriateness and feasibility of students' suggestions for changes.

RESULTS

A significant correlation was found only between the weekly formative assessment and summative scores (r=0.74, p=0.01). The analysis of variance established significant differences between all summative scores of respective periodic formative assessments. The weekly formative assessment showed the highest mean summative examination scores. This study helped comprehend preclinical students' apprehension after the intervention of periodic formative assessments. The students found this intervention helpful in driving and detecting gaps in learning but preferred focused feedback, clinically oriented practices, and countered mental health issues.

CONCLUSION

The continuous periodic formative assessment model had a valid educational impact but was not sustainable according to social sustainability principles. A complex adaptive framework can be utilized to make it sustainable.

Using systems thinking to understand how the South West - School Health Research Network can improve adolescent health and well-being: A qualitative process evaluation

Schools offer a valuable setting to promote good health and mental well-being amongst young people. Schools are complex systems and therefore systems interventions are needed to improve pupil health and well-being. This paper presents a qualitative process evaluation of the South West- School Health Research Network, a systems level intervention. The evaluation is based on interviews with school staff, local authorities and wider stakeholders. Given the complexity of England's educational system there is a need to intervene and monitor health at multiple levels and to ensure close partnership working to effectively improve adolescent health through schools.

Challenges in evaluating implementation and effectiveness in real-world settings: evaluation proposal for school-based health-promoting intervention

There are various research designs and approaches to investigate how health-promoting activities are implemented in complex, real-world systems, and to identify potential health effects that might occur following implementation. Although literature describes guidelines to perform and report about implementation research and effect evaluations, no specific guidelines exist on analysing and reporting about the combination of effectiveness data and implementation data collected as part of intervention evaluation in complex and diverse settings. This paper describes the evaluation of primary school-based health-promoting activities in complex systems. Furthermore, an approach for data categorization inspired by Rogers' Diffusion of Innovations theory is presented that can facilitate structuring the study's results and relating the degree of implementation to any impact on effectiveness outcomes that might be observed. Researchers interested in using this approach for data categorization have to ensure that the following three conditions are met: (i) data on an intervention's efficacy in a controlled setting with optimal implementation is available; (ii) key points that define an intervention's optimal implementation are available and (iii) an evaluation study is performed, collecting both effectiveness data and implementation data in a real-world context. This data categorization approach can be useful to generate more insight into an intervention's effectiveness under varying circumstances, and optimal support and advice can be provided to stakeholders to achieve maximum impact of population-based health-promoting interventions in complex, real-world systems. However, the proposed approach is a first suggestion and further testing and adaptation is necessary to increase its usefulness. Knowledge and experience sharing among researchers performing comparable research can increase the knowledge base regarding this subject.

Mind the gap: Danish school heads' ability to implement a national physical activity school requirement

In 2014, the Danish government introduced a wide-ranging reform of primary and lower secondary education that applied to all public schools. A distinctive feature was that it became mandatory for schools to provide an average of 45 min of daily physical activity (PA). The capacity for change of local school heads and the schools overall are considered key to fulfilling such a policy-driven requirement. The aim of this study is therefore to explore local school heads' ability to implement the stated requirement of 45 min of daily PA within their local organizational capacity for change. Eleven semi-structured interviews were conducted across 11 schools. Respondents were school staff with management responsibilities (leading teachers with school management responsibilities, deputy heads and school heads). Results indicate that local school heads are central agents in converting the Danish school requirement of 45 min of daily PA into local action. This includes their ability to advance broad aims into concrete goals, secure supportive structures and organize the implementation strategy. Heads also need to support the staff in building sufficient knowledge capacity on how to arrange and incorporate PA into their daily practice, support the widespread dissemination of this knowledge across the school and reserve work hours for such activities. Assigning local PA ambassadors was particularly highlighted as important implementation support, as they can help build and disseminate knowledge while also broadcasting the school head's strategy and focus on integrating and upholding students' PA levels.

Rethinking children's physical activity interventions at school: A new context-specific approach

Physical activity is important for children's health. However, evidence suggests that many children and adults do not meet international physical activity recommendations. Current school-based interventions have had limited effect on physical activity and alternative approaches are needed. Context, which includes school setting, ethos, staff, and sociodemographic factors, is a key and largely ignored contributing factor to school-based physical activity intervention effectiveness, impacting in several interacting ways.

Conceptualization

Current programs focus on tightly-constructed content that ignores the context in which the program will be delivered, thereby limiting effectiveness. We propose a move away from uniform interventions that maximize internal validity toward a flexible approach that enables schools to tailor content to their specific context.

Evaluation designs

Evaluation of context-specific interventions should explicitly consider context. This is challenging in cluster randomized controlled trial designs. Thus, alternative designs such as natural experiment and stepped-wedge designs warrant further consideration.

Primary outcome

A collective focus on average minutes of moderate-to-vigorous intensity physical activity may not always be the most appropriate choice. A wider range of outcomes may improve children's physical activity and health in the long-term. In this paper, we argue that greater consideration of school context is key in the design and analysis of school-based physical activity interventions and may help overcome existing limitations in the design of effective interventions and thus progress the field. While this focus on context-specific interventions and evaluation is untested, we hope to stimulate debate of the key issues to improve future physical activity intervention development and implementation.

School-based interventions for preventing dating and relationship violence and gender-based violence: A systematic review and synthesis of theories of change

School-based interventions for preventing dating and relationship violence (DRV) and gender-based violence (GBV) are an important way of attempting to prevent and reduce the significant amount of DRV and GBV that occurs in schools. A theoretical understanding of how these interventions are likely to cause change is essential for developing and evaluating effectiveness, so developing an overarching theory of change for school-based interventions to prevent DRV and GBV was the first step in our systematic review. Theoretical data were synthesised from 68 outcome evaluations using methods common to qualitative synthesis. Specifically, we used a meta-ethnographic approach to develop a line-of-argument for an overarching theory of change and Markham and Aveyard's (2003, Social Science & Medicine, 56, 1209) theory of human functioning and school organisation as a framework for structuring the concepts. The overall theory of change generated was that by strengthening relationships between and among staff and students, between the classroom and the wider school, and between schools and communities, and by increasing students' sense of belonging with student-centred learning opportunities, schools would encourage student commitment to the school and its values, prosocial behaviour and avoidance of violence and aggression. The theory of human functioning informed our understanding of the mechanisms of action but from our analysis we found that it required refinement to address the importance of context and student agency.

The influence of parent-child attachment on school adjustment among the left-behind children of overseas Chinese: The chain mediating role of peer relationships and hometown identity

BACKGROUND

The left-behind children of overseas Chinese are a kind of vulnerable children in the eastern coastal areas of China. Previous studies have shown that there are problems in their school adjustment. This study explored the relationship between parent-child attachment and school adaptation among the left-behind children of overseas Chinese parents, as well as the chain mediating role of peer relationships and hometown identity.

METHODS

A total of 1,047 students in grades 3-8 from 5 schools in Zhejiang Province were selected by cluster sampling. The cross-sectional survey was compiled from the Inventory of Parent and Peer Attachment, the Adaptation subscale of the Adolescent Mental Health Quality Questionnaire-Chinese Version, the Hometown Identity Scale, and the Student Peer Relationship Scale. Structural equation modeling was used to test the conceptual model.

RESULTS

The results showed that the influence of parent-child attachment on school adjustment among the left-behind children of overseas Chinese was mediated by hometown identity. Moreover, this impact was also sequentially mediated by peer relationships and hometown identity.

CONCLUSION

This study revealed peer relationships and hometown identity as underlying mechanism that explained the influence of parent-child attachment on school adjustment among left-behind children. It may provide empirical support for future interventions.

Facilitating conditions for staff's confidence to enforce school tobacco policies: qualitative analysis from seven European cities

Background

School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff’s enforcement. 

Methods

Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3–4 staff members (senior management, teachers, supportive staff) in 3–4 schools (academic–vocational, high–low SES area) were interviewed. Transcripts were analyzed with thematic analysis.

Results

When staff felt confident in their ability to prevent, diminish, or handle students’ negative responses, they were more likely to address students on STP violations. The staff was more confident (1) when consistent policy enforcement within school and regarding the wider society ensured staff legitimacy for STPs enforcement, (2) when dialog and mutual familiarity with students allowed the staff to facilitate constructive interaction with STP violators, and (3) when organizational backup structures provided staff collegial support to overcome challenges in the enforcement. These conditions would support consistent enforcement, especially with persistent misbehavers and among the more uncertain staff members.

Conclusions

Our study stresses the need to implement strategies at multiple levels to strengthen staff’s confidence for STP enforcement. To support staff’s legitimacy for enforcement, we suggest reinforcing structures and practices that facilitate consistency in STP enforcement; to support staff’s ability for constructive interaction with STP violators, we suggest strengthening staff’s social and emotional learning; and to support staff’s experience of collegial support, we suggest reinforcing staff’s collective ability to cope with students’ negative responses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00362-7.

Exploring the implementation dynamics of the Health Promoting School approach in Europe: a qualitative study among school health representatives

Purpose

Adapting the Health Promotion School (HPS) approach to context specifics is acknowledged as being essential for implementation and achieving optimal effectiveness. This study aims to explore implementation variations on seven HPS spectra (such as top-down to bottom-up involvement of stakeholders) on which implementation of the HPS approach can vary, and the factors that relate to navigation on these spectra.

Design/methodology/approach

In 2020, fourteen HPS researchers and professionals from ten European countries participated in semi-structured interviews.

Findings

Navigation variations on the HPS spectra occurred throughout most spectra. Further, a tendency was found towards spectrum extremes of addressing multiple core-components, implementing non-disruptive Health Promotion (HP) programmes, and evaluating the HPS approach through an action-oriented research approach. Important general factors were resources, staff capacity and time available to staff members for implementing the HPS approach. Some spectra required more specific factors like organisational skills, leadership or a certain level of democracy.

Practical implications

The implementation of the HPS approach should be supported by implementation strategies addressing the spectrum-specific factors, but more generic factors such as staff capacity, resources and the level of democracy should also be considered.

Originality/value

This study explores navigation variations throughout HPS spectra rather than the HPS approach in general. It also nuances implementation diversity across and within different European contexts.

Conceptualizing Context and Intervention as a System in Implementation Science: Learning From Complexity Theory Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-country Analysis"

In implementation science, implementation has been widely theorized and assessed. Context, on the other hand, usually played a minor role in the field and was usually conceptualized in a rather positivist way. Despite some promising efforts, there is a strong need to continue building theory on context and operationalizing the concept in implementation practice. I argue for the benefit of integrating complexity theory into our understanding of context in order to further our thinking about context and intervention as a system. This should be reflected by the way in which we build theory as well as apply this theory by employing methods that adequately account for complexity in systems.

Barriers and Facilitators to Sustaining School-Based Mental Health and Wellbeing Interventions: A Systematic Review

Despite an increasing focus on schools to deliver support and education around mental health and wellbeing, interventions are often not sustained beyond initial funding and research. In this review, the barriers and facilitators to sustaining mental health and wellbeing interventions in schools are explored. A systematic review was conducted using keywords based on the terms: 'sustainability', 'school', 'intervention', 'mental health', and 'emotional wellbeing'. Six online databases (PsycINFO, Embase, MEDLINE, British Education Index, ERIC, and Web of Science) and relevant websites were searched resulting in 6160 unique references. After screening, 10 articles were included in the review and extracted data were qualitatively synthesized using thematic analysis. Data synthesis led to the identification of four sustainability factors at the school level (school leadership, staff engagement, intervention characteristics, and resources) and one at the wider system level (external support). These factors were separated into 15 themes and discussed as barriers and facilitators to sustainability (for example, school culture and staff turnover). Most articles included no definition of sustainability, and nearly all barriers and facilitators were discussed at the school level. The findings suggest that more longitudinal and theory-driven research is required to develop a clearer picture of the sustainability process.

‘Shall We Send a Panda?’ A Practical Guide to Engaging Schools in Research: Learning from Large-Scale Mental Health Intervention Trials

The substantial time that children and young people spend in schools makes them important sites to trial and embed prevention and early intervention programmes. However, schools are complex settings, and it can be difficult to maintain school engagement in research trials; many projects experience high levels of attrition. This commentary presents learning from two large-scale, mixed-methods mental health intervention trials in English schools. The paper explores the barriers and challenges to engaging schools in promotion or early intervention research and offers detailed recommendations for other researchers.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review

BACKGROUND

Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions.

METHODS

The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position.

RESULTS

Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after.

CONCLUSIONS

Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Researching two Compassionate Cities: study protocol for a mixed-methods process and outcome evaluation

Background/Objectives:

Compassionate Cities are social ecology approaches that apply a set of actions, targeting a broad range of stakeholders, with the intention of renormalising caring, dying, loss and grieving in everyday life. While several initiatives have been described in the literature, a rigorous evaluation of their processes and outcomes is lacking. This article describes the protocol for a mixed-methods study to evaluate the development process and the outcomes of two Compassionate Cities in Flanders, Belgium.

Methods and Analysis:

We will use a convergent multiphase mixed-methods design, in which a combination of qualitative and quantitative data collection methods will be triangulated in the data analysis stage to capture both development processes and outcomes. Our design includes a quasi-experimental component of a quantitative outcome evaluation in both Compassionate Cities and two comparable control cities with no formal Compassionate City programme. Both Compassionate Cities will be co-created in collaboration with local stakeholders. A critical realism lens will be applied to understand how and why certain processes manifest themselves.

Discussion:

The creation of Compassionate Cities implies high levels of complexity, adaptivity, unpredictability and uncertainty. This requires various data collection methods that can be applied flexibly. A researcher taking on the role of active participant in the project’s development has several advantages, such as access to scholarly information. Reflexivity in this role is paramount to questioning where the ownership of the project lies. By applying a critical realism lens, we remain cautious about our interpretations, and we test the homogeneity of our findings through other forms of data collection.

Conclusion:

This is the first published study protocol to describe both a process and outcome evaluation of a Compassionate City project. By transparently describing our aims and data collection methods, we try to maximise information exchange among researchers and to inform others who desire to implement and evaluate their own initiatives.

The role of school enjoyment and connectedness in the association between depressive and externalising symptoms and academic attainment: Findings from a UK prospective cohort study

BACKGROUND

Previous research on the relationship between children's depressive and externalising symptoms, experience of school, and academic attainment is inconclusive. The aims of this study were (i) to test bidirectional associations between children's school experience and depressive and externalising symptoms at age 10-11 and 13-14, (ii) to ascertain whether school experience age 13-14 is associated with academic attainment age 16, and (iii) to test whether school experience mediates the relationship between depressive or externalising symptoms and attainment.

METHODS

Data was used from the Avon Longitudinal Study of Parents and Children (n=6,409). A cross-lagged model was used to investigate bidirectional associations between school experience (enjoyment and connectedness) and depression and externalising at age 10-11 and 13-14. The same framework was used to test if school experience aged 13-14 mediated associations of depressive and externalising symptoms with later attainment.

RESULTS

Depressive and externalising symptoms at 10-11 were negatively associated with school connectedness (depressive: standardised β=-0.06, CI: -0.11, 0.01; externalizing: β=-0.13, CI: -0.17, -0.08), and school enjoyment at 13-14 (depressive β=-0.04, -0.08, 0.03; externalising: β=-0.08, CI: -0.13, -0.03). School enjoyment at 13-14 was positively associated with attainment at 16 (β=0.10, CI: 0.04, 0.15), and partially mediated associations between depressive and externalising symptoms at 10-11 and attainment at 16 (depressive: proportion mediated 2.2%, CI: -1.5, 5.9; externalising: proportion mediated; 4.7%, CI: 0.7, 10.1,).

LIMITATIONS

Results may be subject to residual confounding.

CONCLUSIONS

School enjoyment is a potentially modifiable risk factor that may affect educational attainment of adolescents with depressive or externalising symptoms.

Behaviours that prompt primary school teachers to adopt and implement physically active learning: a meta synthesis of qualitative evidence

BACKGROUND

Physically active learning (PAL) - integration of movement within delivery of academic content - is a core component of many whole-of-school physical activity approaches. Yet, PAL intervention methods and strategies vary and frequently are not sustained beyond formal programmes. To improve PAL training, a more comprehensive understanding of the behavioural and psychological processes that influence teachers' adoption and implementation of PAL is required. To address this, we conducted a meta-synthesis to synthesise key stakeholders' knowledge of facilitators and barriers to teachers' implementing PAL in schools to improve teacher-focussed PAL interventions in primary (elementary) schools.

METHODOLOGY

We conducted a meta-synthesis using a five-stage thematic synthesis approach to; develop a research purpose and aim, identify relevant articles, appraise studies for quality, develop descriptive themes and interpret and synthesise the literature. In the final stage, 14 domains from the Theoretical Domain Framework (TDF) were then aligned to the final analytical themes and subthemes.

RESULTS

We identified seven themes and 31 sub-themes from 25 eligible papers. Four themes summarised teacher-level factors: PAL benefits, teachers' beliefs about own capabilities, PAL teacher training, PAL delivery. One theme encompassed teacher and school-level factors: resources. Two themes reflected school and external factors that influence teachers' PAL behaviour: whole-school approach, external factors. Ten (of 14) TDF domains aligned with main themes and sub-themes: Knowledge, Skills, Social/Professional Role and Identity, Beliefs about Capabilities, Beliefs about Consequences, Reinforcement, Goals, Environmental Context and Resources, Social influences and Emotion.

CONCLUSIONS

Our synthesis illustrates the inherent complexity required to change and sustain teachers' PAL behaviours. Initially, teachers must receive the training, resources and support to develop the capability to implement and adapt PAL. The PAL training programme should progress as teachers' build their experience and capability; content should be 'refreshed' and become more challenging over time. Subsequently, it is imperative to engage all levels of the school community for PAL to be fully integrated into a broader school system. Adequate resources, strong leadership and governance, an engaged activated community and political will are necessary to achieve this, and may not currently exist in most schools.

Implementing a set of health promoting processes in English secondary schools: A comparative case study

Objective

To understand the enablers and barriers to implementing a set of adaptive processes aimed at supporting secondary schools to reflect on and subsequently address how they could adjust school practices, culture and the environment to create a whole school approach to promoting healthy lifestyles.

Study design

A qualitative, comparative case study.

Methods

Two in depth case studies were created of two purposefully selected schools in low socio-economic areas of South West England. Data were collected via meetings, observations, field notes, interviews and audit. Interviews were transcribed verbatim. Individual thematic analyses were conducted for each school and a comparative analysis approach was used to understand the barriers and enablers across both cases.

Results

Schools were supported to use a health-promoting lens and identify feasible improvements through an adaptive and context specific process. The school environment and ethos were identified as the areas where schools could conceive the most adjustments to enhance the promotion of healthy lifestyle choices. With the lack of government policy for health promotion in schools (HPS), the Head teacher's approach to health was key to making meaningful changes.

Conclusions

Health promoting school approaches need to be adaptive to local context, actively involve community partners and link to local initiatives where possible, with support from Head teachers and business managers. Starting with what teachers, pupils and parents see as the barriers to health can create a whole school ethos for broad reaching and sustainable HPS programmes.

Understanding whole school physical activity transition from a practice theory perspective

Purpose

In this study, the authors offer a practice theory framing of school physical activity transition with conceptual and managerial contributions to whole school approaches (WSAs).

Design/methodology/approach

Based on a literature overview of the limitations of WSA, ecological and systems theorisation and a practice theory framing of physical activity, the authors introduce a model that identifies signs of practice transition and conceptualises the relationship between signs and practice reconfigurations. To exemplify insights from the model, the authors provide illustrations from three cases from the national Estonian “Schools in Motion” programme.

Findings

The signs of practitioner effort, resistance and habituation indicate how practice ecosystem transition is unfolding across a spectrum from practice differentiation to routinisation. Several signs of transition, like resistance, indicate that reconfigured practices are becoming established. Also, there are signs of habituation that seemingly undermine the value of the programme but should instead be celebrated as valuable evidence for the normalisation of new practices.

Practical implications

The article provides a model for WSA programme managers to recognise signs of transition and plan appropriate managerial activities.

Originality/value

The practice theory framing of school physical activity transition advances from extant theorizations of WSAs that have failed to account for the dynamic ways that socio-cultural change in complex school settings can unfold. A model, based on a practice ontology and concepts from theories of practice, is proposed. This recognises signs of transition and can help with the dynamic and reflexive management of transition that retains the purpose of systemic whole school change.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Headteachers' and chairs of governors' perspectives on adolescent obesity and its prevention in English secondary school settings

BACKGROUND

Secondary schools are an important setting for preventing obesity in adolescence. Headteachers and chairs of governors are identified in national guidance as crucial stakeholders for school-based preventative action. Despite this, their views remain unexplored and unrepresented.

METHODS

A sequential mixed method study was conducted. Semi-structured interviews were undertaken with a purposive sample of 22 secondary school headteachers and chairs of governors in England. Data were thematically analysed and informed the development of a descriptive cross-sectional survey, completed by 127 participants from the same population.

RESULTS

Unhealthy dietary and sedentary behaviours were viewed as a more significant problem than adolescent obesity. Obesity was perceived as complex and multi-causal, and a range of stakeholders were deemed to have responsibility for its prevention, most notably parents. Support was identified for the role of secondary schools, although this was not an explicit priority and extensive internal and external barriers exist, which hinder preventative action.

CONCLUSIONS

Whilst secondary school settings in England remain an important setting for the prevention of adolescent obesity, it is crucial for policy makers and public health professionals to recognize the factors affecting school leaders' ability and willingness to contribute to this agenda.

Scaling up Action Schools! BC: How Does Voltage Drop at Scale Affect Student Level Outcomes? A Cluster Randomized Controlled Trial

Action Schools! BC (AS! BC) was scaled-up from an efficacy trial to province-wide delivery across 11 years (2004-2015). In this study we: (1) describe strategies that supported implementation and scale-up; (2) evaluate implementation (teachers' physical activity (PA) delivery) and student's PA and cardiorespiratory fitness (CRF) within a cluster randomized controlled trial during years 2 and 3 of scale-up; and (3) assess relationships between teacher-level implementation and student-level outcomes. We classified implementation strategies as process, capacity-building or scale-up strategies. Elementary schools (n = 30) were randomized to intervention (INT; 16 schools; 747 students) or usual practice (UP; 14 schools; 782 students). We measured teachers' PA delivery (n = 179) using weekly logs; students' PA by questionnaire (n = 30 schools) and accelerometry (n = 9 schools); and students' CRF by 20-m shuttle run (n = 25 schools). INT teachers delivered more PA than UP teachers in year 1 (+33.8 min/week, 95% CI 12.7, 54.9) but not year 2 (+18.8 min/week, 95% CI -0.8, 38.3). Unadjusted change in CRF was 36% and 27% higher in INT girls and boys, respectively, compared with their UP peers (year 1; effect size 0.28-0.48). Total PA delivered was associated with change in children's self-reported MVPA (year 1; r = 0.17, p = 0.02). Despite the 'voltage drop', scaling-up school-based PA models is feasible and may enhance children's health. Stakeholders must conceive of new ways to effectively sustain scaled-up health promoting interventions if we are to improve the health of students at a population level. Clinical Trials registration: NCT01412203.

Multi-age organisation, complexity theory and secondary school reform

Purpose

At a time when many education systems are grappling with the issue of school reform, there is a concern that traditional UK secondary schools are organised in a way that makes them unable to respond to increasingly complex environmental demands. This research-based paper uses complexity theory to gauge the organisational differences between (1) the traditional model of schooling based on same-age organisation and (2) a form of organisation based on multi-age tutor groups, one that schools call a vertical tutoring (VT) system. The intention is to highlight the organisational changes made by schools that choose to transition from their same-age iteration to the VT system, and expose organisational assumptions in the dominant same-age structure that may account for the failure of reform.

Design/methodology/approach

The author's consultancy and research work spans two decades, and includes around 200 UK secondary schools, and others in China, Japan, South Africa, Australia, Qatar, Germany and Colombia. This conceptual paper draws on the recorded discourse and critical reflections of leadership teams during programmes of transformative learning, the process involved in the transition from one system to another. Using descriptions of school organisation abstracted from the complexity literature, differences in the two models not otherwise apparent, come into sharp focus. These not only reveal a substantive connection between organisation, complexity, and individual and organisational learning, but offer insights into the challenge of school reform.

Findings

Same-age organisations act in ways that regulate and restrict the agency of participating actors (staff, students and parents). The effect is to reduce a school’s learning capacity and ability to absorb the value demand on its system. Such a system is closed and non-complex. VT schools construct an open and fluid learning system from the base, deregulating agency. By unfreezing their structure, they intervene in processes of power, necessitating the distribution of leadership to the organisational edge, a process of complexification. The form of organisation chosen by a school explains the failure of reform.

Originality/value

Insights from VT schools cast considerable doubt on the viability of traditional same-age structures to serve complex societies and communities, while highlighting the critical role played by complexity theory in organisational praxis. If correct, the current emphasis on teacher “will and skill”, curricular editing, pedagogy and the “what works agenda” will be insufficient to bring about reformational change and more likely to contribute to systemic stasis.

Feeling Valued and Adding Value: A Participatory Action Research Project on Co-creating Practices of Social Inclusion in Kindergartens and Communities

Background: Contemporary public health problems connect to the social determinants of health, with a growing recognition of social inclusion as imperative to sustainable development. In this quest for social inclusion, early childhood and families are of particular interest. Although co-creation is suggested as viable path to support well-being, less is known how social inclusion might be co-created in practice. The aim of this study was to explore how Participatory Action Research (PAR) can be a tool for transformative practices in a local community, pointing to kindergartens as meeting places for recognizing social inclusion as a common value in early childhood. Methods: A qualitative PAR study was embedded in a Norwegian municipality as an integrated part of their local public health work. The study involved a wide range of participants and stakeholders in three kindergartens and the wider community. Together, we explored potentials for co-creating social inclusion to achieve well-being through cycles of transformative actions and reflections. Reflexive thematic analysis was applied to generate patterns and themes in the data. Results: The participants formulated and took on ownership to an inclusive agenda through the PAR-process. Acts of inclusion was framed by an intersection between political aims of achieving health and well-being for all and public value co-creation unfolding at the level of the place, in the context of the Norwegian welfare regime. To feel valued and adding value was seen as important aspects for social inclusion. Four themes were generated from analysis; (1) Co-creating a shared vision of inclusive communities, (2) Becoming aware and empowered through caring, sharing and collaboration, (3) Places and spaces of inclusiveness in kindergartens and beyond, and (4) Valuing and practicing inclusion, and signs of transformative change. Conclusions: Through the PAR process, parents, kindergartens employees, community members and policy makers appear to have opened a creative toolbox for inclusive and transformational change through formulating and co-creating inclusion and well-being as public values. The results suggest that local actors might support adaptive social systems to taking on relational responsibility for inclusive processes and outcomes in the pursuit of well-being for all.

Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

Background

Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions.

Method

This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data.

Result

We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well.

Conclusion

The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

Are Danish vocational schools ready to implement "smoke-free school hours"? A qualitative study informed by the theory of organizational readiness for change

BACKGROUND

The smoking prevalence is high among students enrolled in vocational education and training, which is considered a lower level of education. The school tobacco policy regarding smoke-free school hours stipulates that students and staff are not allowed to smoke during school hours-inside or outside school premises-and it might be an effective intervention for reducing smoking in vocational schools. For school tobacco policies to be effective, they must be appropriately implemented. A primary predictor for successful implementation is organizational readiness for change. This study seeks to identify and understand the barriers to and facilitators for developing organizational readiness to implement smoke-free school hours in Danish vocational schools.

METHODS

Semi-structured interviews and focus groups were carried out with managers and teachers (n = 22 participants) from six vocational schools. The interview guides were informed by "A theory of organizational readiness for change" developed by Weiner, which was also used as a framework to analyze the data.

RESULTS

We identified 13 facilitators and barriers. Nine factors acted as facilitators, including the following: believing that health promotion is a school role and duty; believing that society and workplaces are becoming more smoke-free, and believing that smoke-free school hours is a beneficial strategy to achieve fewer educational interruptions. Additional facilitators include establishing clear rules for sanctioning and enforcement, developing a joint understanding about smoke-free school hours, developing skills to deal with student responses to smoke-free school hours, establishing social alternatives to smoking, offering smoking cessation help, and mandating smoke-free school hours by law. Four organizational norms, practices, or discourses acted as barriers: believing that smoke-free school hours violate personal freedom, believing that students have more important problems than smoking, believing that it is difficult to administer the level of enforcement, and believing that the enforcement of smoke-free school hours negatively influences student-teacher relations.

DISCUSSION

Our results suggest that developing organizational readiness before adopting a comprehensive tobacco policy such as smoke-free school hours is important for successful implementation. Further research should investigate how to strengthen the facilitators for and counter the barriers to developing readiness for implementing smoke-free school hours.

Implementation of a Dutch school-based integrated approach targeting education, health and poverty-a process evaluation

This study provides an evaluation of the implementation of a school-based integrated approach to improve academic outcomes by targeting children’s education, health, and poverty. A two-year municipal subsidy program was provided to four primary schools in a deprived urban neighborhood in Amsterdam. Schools were put in charge of the implementation and coordination of the program. The municipality and district authorities provided assistance. This study evaluated whether the program functioned as integrated approach, i.e., whether it targeted multiple domains and environments by involving various agencies and actors, and what factors facilitated or hampered this. It also yielded an overview of the initiatives implemented and the facilitators and barriers of successful implementation of initiatives. Principals’ perceptions served as the main input for this study. We thematically analyzed seven written customized plans for spending the subsidy (one to two per school), 15 transcripts of interviews with the principals (three to four per school) and the minutes of 16 meetings between principals, policy officers, and researchers. According to the principals, the schools had made great progress in the education domain and in improving the school’s pedagogical climate, but in the health and poverty domains less progress had been made. Apart from the municipality, relatively few external agencies and actors had been actively involved in the program, and progress in other environments than the school was hardly achieved. This study shows that functioning of the program as integrated approach was facilitated by connections between initiatives, and that hired, well-trusted third parties may be crucial to establish these connections.

Lay summary

This study evaluated whether a two-year municipal program to improve academic outcomes by targeting children’s education, health, and poverty, provided to primary schools in a deprived urban neighborhood, functioned as intended, and if so why, or if not, why not. The program was intended to function as integrated approach. This means that it was supposed to target the mentioned domains, the school, home, and neighborhood environment, and to involve various agencies and actors, such as school staff, policy officers, parents, children, and external organizations. The school principals could implement multiple, self-chosen, initiatives. According to the principals, on whose perceptions this evaluation study was primarily based, both teaching and the school climate improved during the program. However, improvements in children’s health and poverty levels, and outside the school environment in general, were more difficult to achieve. In addition, the program involved mainly school staff and policy officers. The program thus functioned as an integrated approach, but only to a limited extent. The functioning of the program as integrated approach was facilitated by involving hired third parties to stimulate interconnection of initiatives, i.e., initiatives serving the same goals, involving multiple agencies and actors, and/or being implemented in the same location.

A Ban on Smartphone Usage during Recess Increased Children's Physical Activity

School recess provides a unique opportunity for children to be active. However, many children perceive smartphones as a key barrier for engaging in physical activity during recess. The aim was to investigate if a ban on smartphone usage during recess changed children’s physical activity. During August–October 2020, children from grades 4–7 (10–14 years) at six Danish schools were banned from using their smartphones during recess for a four-week period. Questionnaire and systematic observation (SOPLAY) data were collected from 814 children before intervention (baseline) and 828 during the last week of intervention (follow-up). The mean frequency of physical activity significantly increased from baseline to follow-up (odds ratio = 1.370), as did physical activity on a moderate level (odds ratio = 1.387). Vigorous physical activity significantly decreased (odds ratio = 0.851). The increase in physical activity was found among both schools having outdoor and indoor recess, among both boys and girls, and nearly equally among grades 4–7. This suggests that implementing a ban on smartphone usage during recess would improve the everyday conditions for health among a broad range of schoolchildren. Future studies are needed to further investigate the association between recess physical activity and smartphone usage.

Programme theory and realist evaluation of the 'Smoke-Free Vocational Schools' research and intervention project: a study protocol

INTRODUCTION

Smoke-free school hours (SFSHs) entails a smoking ban during school hours and might be an effective intervention to reduce the high smoking prevalence in vocational schools. For SFSH to be effective, the policy must be adequately implemented and enforced; this challenge for schools constitutes a research gap. The 'Smoke-Free Vocational Schools' research and intervention project has been developed to facilitate schools' implementation of SFSH. It is scheduled to run from 2018 to 2022, with SFSH being implemented in 11 Danish vocational schools. This study protocol describes the intervention project and evaluation design of the research and intervention project.

METHODS AND ANALYSIS

The intervention project aims to develop an evidence-based model for implementing SFSH in vocational schools and similar settings. The project is developed in a collaboration between research and practice. Two public health NGOs are responsible for delivering the intervention activities in schools, while the research partner evaluates what works, for whom, and under what circumstances. The intervention lasts one year per school, targeting different socioecological levels. During the first 6 months, activities are delivered to stimulate organisational readiness to implement SFSH. Then, SFSH is established, and during the next 6 months, activities are delivered to stimulate implementation of SFSH into routine practice. The epistemological foundation is realistic evaluation. The evaluation focuses on both implementation and outcomes. Process evaluation will determine the level of implementation and explore what hinders or enables SFSH becoming part of routine practice using qualitative and quantitative methods. Outcomes evaluation will quantitively assess the intervention's effectiveness, with the primary outcome measure being changes in smoking during school hours.

ETHICS AND DISSEMINATION

Informed consent will be obtained from study participants according to the General Data Protection Regulation (GDPR) and Danish data protection law. The study adheres to Danish ethics procedures. Study findings will be disseminated at conferences and further published in open-access peer-reviewed journals.

Why medical journalism wins public health journalism: systems thinking recommendations for health-promoting media

Purpose

Health-related issues are widely covered in news agencies by medical and health journalists. The quantity, format and quality of their coverage influence the general public as well as policymakers and professions. Current studies and observations suggest that news agencies are more dominated by medical topics (disease, symptoms, epidemiology, treatment and medicines) than general public health issues (risk prevention, health protection, education and promotion). This study explores the causes of the current situation in Iran and generates solutions for supporting health-promoting media that may also prove beneficial for other countries.

Design/methodology/approach

A qualitative study was conducted to explore the coverage of health-related topics in selected news agencies. Stakeholders, including health journalists, health professionals and public relations staff at the Iranian Ministry of Health and Medical Education were interviewed. Data were collected until data saturation was reached. The transcripts of all the 17 interviews conducted were analyzed using conventional content analysis.

Findings

Four groups of causes were identified, including individual factors, organizational factors, socioeconomic factors and the different nature of medicine and public health. The participants proposed several solutions that were classified into three categories, including the empowerment of stakeholders through capacity development, organizational change and mutual communication and culture change.

Originality/value

Creating health-promoting media is a complex but urgent task, and providing a comprehensive and deep understanding of the dynamic interdependencies of the multiple factors at play in it and developing and implementing the most effective interventions for it requires a systematic approach.

The longitudinal relationship of school climate with adolescent social and emotional health

Background

Schools and school climate are thought to influence academic outcomes as well as child and adolescent development, health and well-being. We sought to examine the relationship between several aspects of the school climate with adolescent social-emotional health outcomes.

Methods

We analysed data from the Reducing Inequities through Social and Educational change Follow-up (RISE UP) Study, a longitudinal natural experimental study of Los Angeles high school students collected from 2013 to 2018. We analysed data on the portion of the sample that completed the baseline, 10th grade and 11th grade surveys (n=1114). Students reported their perceptions of school climate at 10th grade and social-emotional outcomes including grit, self-efficacy, depression, hopelessness, and stress at baseline (9th grade) and at 11th grade. Multivariable regressions adjusted for student and parental demographics and baseline social-emotional states tested associations between school climate and each outcome.

Results

Students who reported being in authoritative school environments in 10th grade, one that is highly supportive and highly structured, had subsequently higher levels of self-efficacy (p< 0.001) and grit (p=0.01). They also had fewer depressive symptoms (p=0.008), and less hopelessness (p = 0.01), stress at school (p=0.002) and stress about the future (p=0.03) reported in 11th grade.

Conclusions

School climate, and particularly an authoritative school environment, is strongly associated with better social-emotional health among adolescents. Relationship with teachers and their disciplinary style may be a focus for future interventions to improve the social-emotional health of children.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.