Protocol for a systematic review of the effects of schools and school-environment interventions on health: evidence mapping and syntheses

Good School Toolkit-Secondary Schools to prevent violence against students: protocol for a pilot cluster randomised controlled trial

INTRODUCTION

No whole-school interventions which seek to reduce physical, sexual and emotional violence from peers, intimate partners and teachers have been trialled with adolescents. Here, we report a protocol for a pilot trial of the Good School Toolkit-Secondary Schools intervention, to be tested in Ugandan secondary schools. Our main objectives are to (1) refine the intervention, (2) to understand feasibility of delivery of the intervention and (3) to explore design parameters for a subsequent phase III trial.

METHODS AND ANALYSIS

We will conduct a pilot cluster randomised controlled trial, with two arms and parallel assignment. Eight schools will be randomly selected from a stratified list of all eligible schools in Kampala and Wakiso Districts. We will conduct a baseline survey and endline survey 18 months after the baseline, with 960 adolescents and 200 teachers. Qualitative data and mixed methods process data collection will be conducted throughout the intervention. Proportion of staff and students reporting acceptability, understanding and implementing with fidelity will be tabulated at endline for intervention schools. Proportions of schools consenting to participation, randomisation and proportions of schools and individual participants completing the baseline and endline surveys will be described in a Consolidated Standards of Reporting Trials diagram.

ETHICS AND DISSEMINATION

The ethical requirements of our project are complex. Full approvals have been received from the Mildmay Ethics Committee (0407-2019), the Uganda National Council for Science and Technology (SS 6020) and the London School of Hygiene & Tropical Medicine (16212). Results of this study will be published in peer-reviewed academic journals, and shared with public bodies, policy makers, study participants and the general public in Uganda.

TRIAL REGISTRATION NUMBER

PACTR202009826515511.

School-Based Nutrition Interventions in Children Aged 6 to 18 Years: An Umbrella Review of Systematic Reviews

Schools are identified as a key setting to influence children’s and adolescents’ healthy eating. This umbrella review synthesised evidence from systematic reviews of school-based nutrition interventions designed to improve dietary intake outcomes in children aged 6 to 18 years. We undertook a systematic search of six electronic databases and grey literature to identify relevant reviews of randomized controlled trials. The review findings were categorised for synthesis by intervention type according to the World Health Organisation Health Promoting Schools (HPS) framework domains: nutrition education; food environment; all three HPS framework domains; or other (not aligned to HPS framework domain). Thirteen systematic reviews were included. Overall, the findings suggest that school-based nutrition interventions, including nutrition education, food environment, those based on all three domains of the HPS framework, and eHealth interventions, can have a positive effect on some dietary outcomes, including fruit, fruit and vegetables combined, and fat intake. These results should be interpreted with caution, however, as the quality of the reviews was poor. Though these results support continued public health investment in school-based nutrition interventions to improve child dietary intake, the limitations of this umbrella review also highlight the need for a comprehensive and high quality systematic review of primary studies.

The school policy, social, and physical environment and change in adolescent physical activity: An exploratory analysis using the LASSO

PURPOSE

We examined the association between the school policy, social and physical environment and change in adolescent physical activity (PA) and explored how sex and socioeconomic status modified potential associations.

METHODS

Data from the GoActive study were used for these analyses. Participants were adolescents (n = 1765, mean age±SD 13.2±0.4y) from the East of England, UK. Change in longitudinal accelerometer assessed moderate-to-vigorous physical activity (MVPA) was the outcome. School policy, social and physical environment features (n = 267) were exposures. The least absolute shrinkage and selection operator variable selection method (LASSO) was used to determine exposures most relevant to the outcome. Exposures selected by the LASSO were added to a multiple linear regression model with estimates of change in min/day of MVPA per 1-unit change in each exposure reported. Post-hoc analyses, exploring associations between change in variables selected by the LASSO and change in MVPA, were undertaken to further explain findings.

FINDINGS

No school policy or physical environment features were selected by the LASSO as predictors of change in MVPA. The LASSO selected two school social environment variables (participants asking a friend to do physical activity; friend asking a participant to do physical activity) as potential predictors of change in MVPA but no significant associations were found in subsequent linear regression models for all participants (β [95%CI] -1.01 [-2.73;0.71] and 0.65 [-2.17;0.87] min/day respectively). In the post-hoc analyses, for every unit increase in change in participants asking a friend to do PA and change in a friend asking participants to do PA, an increase in MVPA of 2.78 (1.55;4.02) and 1.80 (0.48;3.11) min/day was predicted respectively.

CONCLUSIONS

The school social environment is associated with PA during adolescence. Further exploration of how friendships during adolescence may be leveraged to support effective PA promotion in schools is warranted.

Health Literacy: An Interactive Outcome Among Secondary Students in Beijing

Background:

Health literacy enables a person to make good decisions regarding health care, disease prevention, and health promotion to maintain and improve health. Although health literacy research in China has gained increasing attention in recent years, most existing studies focus on adults rather than adolescents. In addition, little theory-driven empirical research has been conducted to fully understand the relationship among health literacy, its influencing factors, and health outcomes scored on a skills-based health literacy instrument.

Objective:

This study applied Manganello's framework to investigate how health literacy was related to its antecedents and health status in secondary students in Beijing, China.

Methods:

A cross-sectional study was conducted with 650 students in Years 7 to 9 (age 11–17 years) from four secondary schools. Students completed a self-administered questionnaire based on Manganello's health literacy framework, which measured key upstream determinants, including health literacy and self-report health status. Health literacy was measured on an 8-item skills-based instrument that assesses a person's ability to find, understand, appraise, and communicate health information in everyday life (scores range from 0–37). Descriptive statistics and path analysis were conducted to investigate the mediating role of health literacy in predicting health status.

Key Results:

Overall, the average scores of students' health literacy was 26.37 (±5.89). Manganello's framework was supported by the data collected (χ²/df = 2.049, p = .001, comparative fix index = 0.966, root mean square error of approximation = 0.041). Personal self-efficacy (r = 0.11, p = .007), social support (r = 0.18, p < .001), and school environment (r = 0.27, p < .001) predicted health literacy, which in turn predicted students' health status (r = 0.12, p = .005).

Conclusions:

Adolescent health literacy is not only a person's capability to protect health, but also an interactive outcome with the broader environment. Promoting health literacy could be a useful strategy to improve health status for adolescents; however, a holistic approach is needed to increase students' self-efficacy, promote social support, and create positive school environments to achieve optimal health literacy and health outcomes. [HLRP: Health Literacy Research and Practice. 2021;5(1):e1–e14.]

Plain Language Summary:

We investigated how health literacy was related to its influencing factors and health status among secondary students in Years 7 to 9 in Beijing, China. Students with low self-efficacy, low social support, and low perceptions of positive school environment were more likely to have low health literacy, which in turn predicted poor health status.

School as ideal setting to promote health and wellbeing among young people

Background: Nowadays, young people face several health challenges. As children and teenagers spend most of their time in the classroom, schools may have the opportunity to positively influence students’ quality of life, playing a crucial role in fostering their health. The aim of this review was to analyze evidence that demonstrated why school is the ideal setting for thepromotion of young generations’ wellbeing.

Methods: We have reviewed the available literature about health promotion in school setting, searching for articles and books published from 1977 to 2020. A total of 74 articles and 17books were selected and assessed.

Results: The promotion of students’ wellbeing could reduce the prevalence of measurable unhealthy outcomes and improve their academic achievements. At least 80% of all cases of heart diseases, strokes, type 2 diabetes and one third of all cancers can be prevented through health education. In this perspective, primary prevention and health promotion should start as early as possible, finding in the school the ideal setting of action. Effective school-based preventive approaches should raise students’ motivation towards a personal interiorization of health knowledge and develop in young people a critical thinking about harmful consequences of the most common risky behaviours. Educators should receive adequate training concerning health topics and become expert in the most innovative approaches to effectively engage students in adopting healthy lifestyles.

Conclusion: As primary educational institution, school should integrate students’ health promotion in its ordinary teaching and learning practices in the perspective of "better health through better schools".

Understanding further education as a context for public health intervention: qualitative findings from a study process evaluation

BACKGROUND

Over 1.2 million 16-18 year-olds are enrolled in further education (FE-advanced secondary education) in England. Life course transitions provide opportunities to change, establish or reinforce health behaviours. FE presents an opportunity for public health improvement, yet few interventions target this setting. Using a smoking prevention intervention, we explore how young people were viewed in FE and how this affected intervention acceptability.

METHODS

Eleven student and five staff focus groups were conducted in three intervention institutions (two colleges, one school sixth-form), as part of the process evaluation of a smoking prevention feasibility study. FE managers in intervention and control institutions were also interviewed (n = 5). Data were analysed using thematic analysis.

RESULTS

In both colleges and the sixth-form, students were viewed as emergent adults and treated differently from 'school-children', in practice if not in policy. Colleges permitted smoking in designated areas; in the school sixth-form smoking was unofficially tolerated but concealed from younger students. Using staff to deliver anti-smoking messages reintroduced an unwanted power dynamic which disrupted perceptions of students as young adults.

CONCLUSIONS

FE is an important setting for young people's health. Understanding the culture and context of FE is critical in designing acceptable and effective public health interventions.

Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map

Because health systems are conceptualized as social systems, embedded in social contexts and shaped by human agency, values are a key factor in health system change. As such, health systems software-including values, norms, ideas and relationships-is considered a foundational focus of the field of health policy and systems research (HPSR). A substantive evidence-base exploring the influence of software factors on system functioning has developed but remains fragmented, with a lack of conceptual clarity and theoretical coherence. This is especially true for work on 'social values' within health systems-for which there is currently no substantive review available. This study reports on a systematic mixed-methods evidence mapping review on social values within HPSR. The study reaffirms the centrality of social values within HPSR and highlights significant evidence gaps. Research on social values in low- and middle-income country contexts is exceedingly rare (and mostly produced by authors in high-income countries), particularly within the limited body of empirical studies on the subject. In addition, few HPS researchers are drawing on available social science methodologies that would enable more in-depth empirical work on social values. This combination (over-representation of high-income country perspectives and little empirical work) suggests that the field of HPSR is at risk of developing theoretical foundations that are not supported by empirical evidence nor broadly generalizable. Strategies for future work on social values in HPSR are suggested, including: countering pervasive ideas about research hierarchies that prize positivist paradigms and systems hardware-focused studies as more rigorous and relevant to policy-makers; utilizing available social science theories and methodologies; conceptual development to build common framings of key concepts to guide future research, founded on quality empirical research from diverse contexts; and using empirical evidence to inform the development of operationalizable frameworks that will support rigorous future research on social values in health systems.

School health education program in Pakistan (SHEPP)-a threefold health education feasibility trial in schoolchildren from a lower-middle-income country

Background

The school environment plays an essential role in promoting health education and physical activity for children and adolescence, and they are more likely to adapt it into their adulthood. School health education program has been endorsed and emphasized by the World Health Organization has not been implemented in true spirit in Pakistan yet. We aim to test feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors by including BP, BMI, and waist circumference.

Methods

It is a parallel-group feasibility intervention trial. It is being conducted in two schools from lower to middle-income areas, at different locations but having the same school curriculum under the Aga Khan Education Service, Pakistan (AKESP). All children aged 9-11 years enrolled from the schools mentioned above were included. Children with any physical disability were excluded. One school received threefold intervention (focused on children, parents, and teachers) of school health education program in Pakistan (SHEPP) while the other school continued routine activity. Intervention of SHEPP is directed towards educating children, parents, and teachers about healthy behaviors. Children will receive interactive educational sessions and specially designed physical activity sessions. A 3-h health education session focusing on same healthy behaviors as for children will be conducted for both parents and teachers. Primary outcome is feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes are physical activity levels, dietary intake (of fruits, vegetable), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). The total number of children recruited were 982 (82.5 %); 505 from school A and 477 from school B and 496 (50.5) were boys.

Conclusion

SHEPP is a unique health education program for children as it focuses on children while involving the parents and teachers in the behavior change process. If found feasible and demonstrating potential efficacy on physical activity, dietary behaviors, and cardiometabolic parameters, we will be able to replicate this on a larger scale in public sector schools also.

Trial registration

NCT03303287

The development and pilot testing of an adolescent bullying intervention in Indonesia - the ROOTS Indonesia program

Bullying has been described as one of the most tractable risk factors for poor mental health and educational outcomes, yet there is a lack of evidence-based interventions for use in low and middle-income settings. We aimed to develop and assess the feasibility of an adolescent-led school intervention for reducing bullying among adolescents in Indonesian secondary schools. The intervention was developed in iterative stages: identifying promising interventions for the local context; formative participatory action research to contextualize proposed content and delivery; and finally two pilot studies to assess feasibility and acceptability in South Sulawesi and Central Java. The resulting intervention combines two key elements: 1) a student-driven design to influence students pro-social norms and behavior, and 2) a teacher-training component designed to enhance teacher’s knowledge and self-efficacy for using positive discipline practices. In the first pilot study, we collected data from 2,075 students in a waitlist-controlled trial in four schools in South Sulawesi. The pilot study demonstrated good feasibility and acceptability of the intervention. We found reductions in bullying victimization and perpetration when using the Forms of Bullying Scale. In the second pilot study, we conducted a randomised waitlist controlled trial in eight schools in Central Java, involving a total of 5,517 students. The feasibility and acceptability were good. The quantitative findings were more mixed, with bullying perpetration and victimization increasing in both control and intervention schools. We have designed an intervention that is acceptable to various stakeholders, feasible to deliver, is designed to be scalable, and has a clear theory of change in which targeting adolescent social norms drives behavioral change. We observed mixed findings across different sites, indicating that further adaptation to context may be needed. A full-randomized controlled trial is required to examine effectiveness and cost-effectiveness of the program.

School experiences and young women's pregnancy and parenthood decisions: A systematic review and synthesis of qualitative research

Schools are considered high-potential environments for promoting adolescent sexual and reproductive health outcomes among young women. Qualitative studies provide context and meaning to how school experiences and systems contribute to pregnancy and parenthood decisions from the perspectives of youth. This systematic review screened 24,711 references from 8 databases, yielding 28 qualitative studies. Included studies were assessed for quality and synthesised using meta-ethnographic approaches. Reciprocal translation revealed that young women's education and life trajectories were at least partially shaped by a commitment to school values and expectations for academic achievement, influenced by structural and relational factors within the school. These findings resonate with Markham and Aveyard's theory of human functioning and school organisation. Future policy and practices might seek to improve teacher-student interactions, leverage young women's developing autonomy, and ensure physically and psychologically safe spaces for students.

Economic evaluation of the Good School Toolkit: an intervention for reducing violence in primary schools in Uganda

Introduction

This paper presents the cost and cost-effectiveness of the Good School Toolkit (GST), a programme aimed at reducing physical violence perpetrated by school staff to students in Uganda.

Methods

The effectiveness of the Toolkit was tested with a cluster randomised controlled trial in 42 primary schools in Luwero District, Uganda. A full economic costing evaluation and cost-effectiveness analysis were conducted alongside the trial. Both financial and economic costs were collected retrospectively from the provider’s perspective to estimate total and unit costs.

Results

The total cost of setting up and running the Toolkit over the 18-month trial period is estimated at US$397 233, excluding process monitor (M&E) activities. The cost to run the intervention is US$7429 per school annually, or US$15 per primary school pupil annually, in the trial intervention schools. It is estimated that the intervention has averted 1620 cases of past-week physical violence during the 18-month implementation period. The total cost per case of violence averted is US$244, and the annual implementation cost is US$96 per case averted during the trial.

Conclusions

The GST is a cost-effective intervention for reducing violence against pupils in primary schools in Uganda. It compares favourably against other violence reduction interventions in the region.

Disclosure of domestic violence and sexual assault within the context of abortion: meta-ethnographic synthesis of qualitative studies protocol

BACKGROUND

One third of women will have an abortion in their lifetime (Kerr, QUT Law Rev 14:15, 2014; Aston and Bewley, Obstetrician & Gynaecologist 11:163-8, 2009). These women are more likely to have experienced domestic violence or sexual assault than women who continue with their pregnancies. Frontline health personnel involved in the care of women seeking abortions are uniquely positioned to support patients who choose to disclose their violence. Yet, the disclosure of domestic violence or sexual assault within the context of abortion is not well understood. To enhance service provision, it is important to understand the disclosure experience, that is, how frontline health personnel manage such disclosures and how victims/survivors perceive this experience. This review aims to provide a systematic synthesis of qualitative literature to increase understanding of the phenomena and identify research gaps.

METHODS

A meta-ethnography of qualitative evidence following PRISMA-P recommendations for reporting systematic reviews will be performed to better understand the experiences of domestic violence and sexual assault disclosure from the perspective of frontline health personnel providing support and women seeking an abortion. A three-stage search strategy including database searching, citation searching and Traditional Pearl Growing will be applied starting with the terms "domestic violence", "sexual assault", "disclosure" and "abortion", their common synonyms and MeSH terms. The database search will include CINAHL, MEDLINE, Embase and PsycINFO. Published studies from 1970, written in English and from all countries will be included. Two reviewers will screen titles and abstracts and if suitable will then perform a full-text review. To attribute weight to each study, two reviewers will perform the critical appraisal using a modified version of the "Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research". Data extraction and coding will occur using EPPI-Reviewer 4 and will be carried out by two reviewers.

DISCUSSION

The reviewers will illuminate what transpires at the interface when women seeking an abortion in the context of domestic violence and sexual assault meet frontline health personnel. Increased knowledge in this area will improve the frontline health personnel's practices and responsiveness to women who seek out healthcare in the context of violence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016051136.

Does the Good Schools Toolkit Reduce Physical, Sexual and Emotional Violence, and Injuries, in Girls and Boys equally? A Cluster-Randomised Controlled Trial

We aimed to investigate whether the Good School Toolkit reduced emotional violence, severe physical violence, sexual violence and injuries from school staff to students, as well as emotional, physical and sexual violence between peers, in Ugandan primary schools. We performed a two-arm cluster randomised controlled trial with parallel assignment. Forty-two schools in one district were allocated to intervention (n = 21) or wait-list control (n = 21) arms in 2012. We did cross-sectional baseline and endline surveys in 2012 and 2014, and the Good School Toolkit intervention was implemented for 18 months between surveys. Analyses were by intention to treat and are adjusted for clustering within schools and for baseline school-level proportions of outcomes. The Toolkit was associated with an overall reduction in any form of violence from staff and/or peers in the past week towards both male (aOR = 0.34, 95%CI 0.22-0.53) and female students (aOR = 0.55, 95%CI 0.36-0.84). Injuries as a result of violence from school staff were also lower in male (aOR = 0.36, 95%CI 0.20-0.65) and female students (aOR = 0.51, 95%CI 0.29-0.90). Although the Toolkit seems to be effective at reducing violence in both sexes, there is some suggestion that the Toolkit may have stronger effects in boys than girls. The Toolkit is a promising intervention to reduce a wide range of different forms of violence from school staff and between peers in schools, and should be urgently considered for scale-up. Further research is needed to investigate how the intervention could engage more successfully with girls.

School composition, school culture and socioeconomic inequalities in young people's health: Multi-level analysis of the Health Behaviour in School-aged Children (HBSC) survey in Wales

Health inequalities emerge during childhood and youth, before widening in adulthood. Theorising, testing and interrupting the mechanisms through which inequalities are perpetuated and sustained is vital. Schools are viewed as settings through which inequality in young people's health may be addressed, but few studies examine the social processes via which institutional structures reproduce or mitigate health inequalities. Informed by Markham and Aveyard's theory of human functioning and school organisation, including their concept of institutional boundaries, critical theories of marketisation and the concept of micro-political practices within schools, this paper presents analysis of student survey data (N = 9055) from 82 secondary schools in Wales. It examines the role of socioeconomic composition, social relationships at school and institutional priorities in mitigating or perpetuating health inequality. It finds that affluent schools were most unequal in terms of student health behaviours and subjective wellbeing. In relation to health behaviours, students from affluent families accrue a disproportionate benefit. For wellbeing, students from poorer families reported lower subjective wellbeing where attending more affluent schools. Student-staff relationships appear to be a key mechanism underpinning these effects: poor relationships with staff were predicted by a pupil's position within schools' socioeconomic hierarchy and associated with worse health outcomes. That is, students from the poorest families reported better relationships with teachers where attending less affluent schools. Universal approaches engaging with these social processes are needed to reduce health inequalities.

Engaging stakeholders and target groups in prioritising a public health intervention: the Creating Active School Environments (CASE) online Delphi study

OBJECTIVES

Stakeholder engagement and public involvement are considered as integral to developing effective public health interventions and is encouraged across all phases of the research cycle. However, limited guidelines and appropriate tools exist to facilitate stakeholder engagement-especially during the intervention prioritisation phase. We present the findings of an online 'Delphi' study that engaged stakeholders (including young people) in the process of prioritising secondary school environment-focused interventions that aim to increase physical activity.

SETTING

Web-based data collection using an online Delphi tool enabling participation of geographically diverse stakeholders.

PARTICIPANTS

37 stakeholders participated, including young people (age 13-16 years), parents, teachers, public health practitioners, academics and commissioners; 33 participants completed both rounds.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked to prioritise a (short-listed) selection of school environment-focused interventions (eg, standing desks, outdoor design changes) based on the criteria of 'reach', 'equality', 'acceptability', 'feasibility', 'effectiveness' and 'cost'. Participants were also asked to rank the criteria and the effectiveness outcomes (eg, physical activity, academic achievement, school enjoyment) from most to least important. Following feedback along with any new information provided, participants completed round 2 4 weeks later.

RESULTS

The intervention prioritisation process was feasible to conduct and comments from participants indicated satisfaction with the process. Consensus regarding intervention strategies was achieved among the varied groups of stakeholders, with 'active lessons' being the favoured approach. Participants ranked 'mental health and well-being' as the most important outcome followed by 'enjoyment of school'. The most important criteria was 'effectiveness', followed by 'feasibility'.

CONCLUSIONS

This novel approach to engaging a wide variety of stakeholders in the research process was feasible to conduct and acceptable to participants. It also provided insightful information relating to how stakeholders prioritise interventions. The approach could be extended beyond the specific project to be a useful tool for researchers and practitioners.

Intraclass correlation values for adolescent health outcomes in secondary schools in 21 European countries

BACKGROUND

Cluster randomised controlled trials (CRCTs) are increasingly used to evaluate the effectiveness of interventions for improving health. A key feature of CRCTs is that individuals in clusters are often more alike than individuals in different clusters, irrespective of treatment. This similarity within clusters needs to be taken into account when planning CRCTs to obtain adequate sample sizes, and when analysing clustered data to obtain correct estimates.

METHODS

Nationally representative data from 15 to 16 year olds were analysed, from 21 of the 35 countries that participated in the 2007 European School Survey Project on Alcohol and Other Drugs. Within country school level intra-class correlation coefficients (ICCs) were calculated for substance use (self-reported alcohol use, regular alcohol use, binge drinking, any smoking, regular smoking, and illicit drug use) and psychosocial health (depressive mood and self-esteem). Unadjusted and adjusted ICCs are presented. ICCs are adjusted for student sex and socioeconomic status.

RESULTS

ICCs ranged from 0.01 to 0.21, with the highest (0.21) reported for regular smoking. Within country school level ICCs varied substantially across health outcomes, and among countries for the same health outcomes. Estimated ICCs were consistently higher for substance use (range 0.01-0.21), than for psychosocial health (range 0.01-0.07). Within country ICCs for health outcomes varied by changes in the measurement of particular health outcomes, for example the ICCs for regular smoking (range 0.06-0.21) were higher than those for having smoked at all in the last month (range 0.03-0.17).

CONCLUSIONS

For school level ICCs to be effectively utilised in informing sample size requirements for CRCTs and adjusting estimates from meta-analyses, the school level ICCs need to be both country and outcome specific.

Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions

The integration of realist evaluation principles within randomised controlled trials ('realist RCTs') enables evaluations of complex interventions to answer questions about what works, for whom and under what circumstances. This allows evaluators to better develop and refine mid-level programme theories. However, this is only one phase in the process of developing and evaluating complex interventions. We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework. Intervention development, modelling, and feasibility and pilot studies need to theorise the contextual conditions necessary for intervention mechanisms to be activated. Where interventions are scaled up and translated into routine practice, realist principles also have much to offer in facilitating knowledge about longer-term sustainability, benefits and harms. Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups.

Influence of school-related factors on smoking among Chilean adolescents: a cross-sectional multilevel study

BACKGROUND

Adolescent tobacco smoking is a major health concern in Chile. Schools may be able to influence adolescent behaviour regarding smoking; however, this topic has received limited research attention in Latin-American countries. Moreover, the prevalence of cigarette smoking varies between schools, and some of this variability may be explained by school factors. This article examines the inter-school variability in student smoking in a large sample of Chilean schools and identifies the school- and student-level characteristics associated with cigarette smoking.

METHODS

This cross-sectional study used self-reported student-level data from 45,273 students from 1462 schools and official data from these schools provided by the Chilean Ministry of Education (2007). Student smoking behaviour was used as an outcome, and individual-level and school-level features were used as explanatory variables. Logistic multilevel modelling was used to analyse the data.

RESULTS

The mean prevalence of smoking in the 1462 schools was 39.9 %. The null model indicated that 8 % of the variance in smoking behaviour was explained by schools; and in the final model, controlled by individual- and school-level variables, the variance explained by schools dropped to 2.4 %. The main school-level variables explaining the school influence were school bonding, school truancy and school achievement.

CONCLUSIONS

This is the first study to examine the extent to which student smoking varies between Chilean schools and to identify some of the school factors associated with this inter-school variability. Although most variation in smoking prevalence lies between students within schools, there is sufficient between-school variation to be of interest to educators and policy makers.

Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors

BACKGROUND

We investigated whether adolescents drank alcohol less frequently if they lived in jurisdictions with school climates that were more affirmative of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals.

METHODS

Data from the 2010 School Health Profile survey, which measured LGBTQ school climate (e.g., percentage of schools with safe spaces and gay-straight alliances), were linked with pooled data from the 2005 and 2007 Youth Risk Behavior Survey, which measured sexual orientation identity, demographics, and alcohol use (number of drinking days, drinking days at school, and heavy episodic drinking days) in 8 jurisdictions. Two-level Poisson models tested the associations between school climate and alcohol use for each sexual-orientation subgroup.

RESULTS

Living in jurisdictions with more (versus less) affirmative LGBTQ school climates was significantly associated with: fewer heavy episodic drinking days for gay/lesbian (incidence-rate ratio [IRR]=0.70; 95% confidence interval [CI]: 0.56, 0.87; p=0.001) and heterosexual (IRR=0.80; 95% CI: 0.76, 0.83; p<0.001) adolescents; and fewer drinking days at school for adolescents unsure of their sexual orientation (IRR=0.57; 95% CI: 0.35, 0.93; p=0.024).

CONCLUSIONS

Fostering LGBTQ-affirmative school climates may reduce certain drinking behaviors for gay/lesbian adolescents, heterosexual adolescents, and adolescents unsure of their sexual orientation.

The school environment and adolescent physical activity and sedentary behaviour: a mixed-studies systematic review

There is increasing academic and policy interest in interventions aiming to promote young people's health by ensuring that the school environment supports healthy behaviours. The purpose of this review was to summarize the current evidence on school-based policy, physical and social-environmental influences on adolescent physical activity and sedentary behaviour. Electronic databases were searched to identify studies that (1) involved healthy adolescents (11-18 years old), (2) investigated school-environmental influences and (3) reported a physical activity and/or sedentary behaviour outcome or theme. Findings were synthesized using a non-quantitative synthesis and thematic analysis. Ninety-three papers of mixed methodological quality were included. A range of school-based policy (e.g. break time length), physical (e.g. facilities) and social-environmental (e.g. teacher behaviours) factors were associated with adolescent physical activity, with limited research on sedentary behaviour. The mixed-studies synthesis revealed the importance of specific activity settings (type and location) and intramural sport opportunities for all students. Important physical education-related factors were a mastery-oriented motivational climate and autonomy supportive teaching behaviours. Qualitative evidence highlighted the influence of the wider school climate and shed light on complexities of the associations observed in the quantitative literature. This review identifies future research needs and discusses potential intervention approaches to be considered.

Exploring the Potential of a School Impact on Pupil Weight Status: Exploratory Factor Analysis and Repeat Cross-Sectional Study of the National Child Measurement Programme

Schools are common sites for obesity prevention interventions. Although many theories suggest that the school context influences weight status, there has been little empirical research. The objective of this study was to explore whether features of the school context were consistently and meaningfully associated with pupil weight status (overweight or obese). Exploratory factor analysis of routinely collected data on 319 primary schools in Devon, England, was used to identify possible school-based contextual factors. Repeated cross-sectional multilevel analysis of five years (2006/07-2010/11) of data from the National Child Measurement Programme was then used to test for consistent and meaningful associations. Four school-based contextual factors were derived which ranked schools according to deprivation, location, resource and prioritisation of physical activity. None of which were meaningfully and consistently associated with pupil weight status, across the five years. The lack of consistent associations between the factors and pupil weight status suggests that the school context is not inherently obesogenic. In contrast, incorporating findings from education research indicates that schools may be equalising weight status, and obesity prevention research, policy and practice might need to address what is happening outside schools and particularly during the school holidays.

Development and validation of a questionnaire to evaluate lifestyle-related behaviors in elementary school children

Background

The SI! Program promotes cardiovascular health through a multilevel school-based intervention on four lifestyle-related components: diet, physical activity, understanding the body and heart, and management of emotions. We report here the development and validation of the KAH (knowledge, attitudes and habits)-questionnaire adapted for elementary school children (6–7 years old) as a tool for the forthcoming evaluation of the SI! Program, where the KAH scoring will be the primary outcome. The efficacy of such an intervention will be based on the improvements in children’s KAH towards a healthy lifestyle.

Methods

The questionnaire validation process started with a pool of items proposed by the pedagogical team who developed the SI! Program for elementary school. The questionnaire was finalized by decreasing the number of items from 155 to 48 using expert panels and statistical tests on the responses from 384 children (ages 6–7). A team of specialized psychologists administered the questionnaire at schools providing standard directions for the final administration. The internal consistency was assessed using Cronbach’s α coefficients. Reliability was measured through the split-half method, and problematic items were detected applying the item response theory. Analysis of variance and Tukey’s test of additivity were used for multiple comparisons.

Results

The final KAH-questionnaire for elementary school children should be administered to children individually by trained staff. The 48 items-questionnaire is divided evenly between the 4 components of the intervention, with an overall Cronbach’s α = 0.791 (α = 0.526 for diet, α = 0.537 for physical activity, α = 0.523 for human body and heart, and α = 0.537 for management of emotions).

Conclusions

The KAH-questionnaire is a reliable instrument to assess the efficacy of the SI! Program on instilling healthy lifestyle-related behaviors in elementary school children.

Electronic supplementary material

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The World Health Organization's Health Promoting Schools framework: a Cochrane systematic review and meta-analysis

BACKGROUND

Healthy children achieve better educational outcomes which, in turn, are associated with improved health later in life. The World Health Organization's Health Promoting Schools (HPS) framework is a holistic approach to promoting health and educational attainment in school. The effectiveness of this approach has not yet been rigorously reviewed.

METHODS

We searched 20 health, education and social science databases, and trials registries and relevant websites in 2011 and 2013. We included cluster randomised controlled trials. Participants were children and young people aged four to 18 years attending schools/colleges. HPS interventions had to include the following three elements: input into the curriculum; changes to the school's ethos or environment; and engagement with families and/or local communities. Two reviewers identified relevant trials, extracted data and assessed risk of bias. We grouped studies according to the health topic(s) targeted. Where data permitted, we performed random-effects meta-analyses.

RESULTS

We identified 67 eligible trials tackling a range of health issues. Few studies included any academic/attendance outcomes. We found positive average intervention effects for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small. On average across studies, we found little evidence of effectiveness for zBMI (BMI, standardized for age and gender), and no evidence for fat intake, alcohol use, drug use, mental health, violence and bullying others. It was not possible to meta-analyse data on other health outcomes due to lack of data. Methodological limitations were identified including reliance on self-reported data, lack of long-term follow-up, and high attrition rates.

CONCLUSION

This Cochrane review has found the WHO HPS framework is effective at improving some aspects of student health. The effects are small but potentially important at a population level.

Consulting with young people to inform systematic reviews: an example from a review on the effects of schools on health

BACKGROUND

There has been increasing interest in involving the public in systematic reviews as they provide a shortcut to the evidence and arguably have greater influence over policy decisions and ultimately people's lives. Case examples of this involvement are rare, especially for reviews focused on children and young people. This study describes the process and impact of consulting with a young people's advisory group to inform decision making in a systematic review on the effects of schools and school environment interventions on children and young people's health.

METHODS

Consultations were conducted with a pre-existing group of young people brought together to advise on public health research. Their views were sought at two key stages: (i) at the beginning when general views relating to the policy problem under study were elicited; and (ii) half-way through to advise on how to focus the review on key priorities.

RESULTS

Young people's involvement in our review ensured that the scope of our review was appropriate and that issues which were important to young people were considered. The group was especially valuable in terms of prioritizing in a relevant and meaningful way. A crucial additional impact of involvement was young people providing 'early signals' of key themes for the synthesis.

Considering methodological options for reviews of theory: illustrated by a review of theories linking income and health

BACKGROUND

Review of theory is an area of growing methodological advancement. Theoretical reviews are particularly useful where the literature is complex, multi-discipline, or contested. It has been suggested that adopting methods from systematic reviews may help address these challenges. However, the methodological approaches to reviews of theory, including the degree to which systematic review methods can be incorporated, have received little discussion in the literature. We recently employed systematic review methods in a review of theories about the causal relationship between income and health.

METHODS

This article discusses some of the methodological issues we considered in developing the review and offers lessons learnt from our experiences. It examines the stages of a systematic review in relation to how they could be adapted for a review of theory. The issues arising and the approaches taken in the review of theories in income and health are considered, drawing on the approaches of other reviews of theory.

RESULTS

Different approaches to searching were required, including electronic and manual searches, and electronic citation tracking to follow the development of theories. Determining inclusion criteria was an iterative process to ensure that inclusion criteria were specific enough to make the review practical and focused, but not so narrow that key literature was excluded. Involving subject specialists was valuable in the literature searches to ensure principal papers were identified and during the inductive approaches used in synthesis of theories to provide detailed understanding of how theories related to another. Reviews of theory are likely to involve iterations and inductive processes throughout, and some of the concepts and techniques that have been developed for qualitative evidence synthesis can be usefully translated to theoretical reviews of this kind.

CONCLUSIONS

It may be useful at the outset of a review of theory to consider whether the key aim of the review is to scope out theories relating to a particular issue; to conduct in-depth analysis of key theoretical works with the aim of developing new, overarching theories and interpretations; or to combine both these processes in the review. This can help decide the most appropriate methodological approach to take at particular stages of the review.

Considering methodological options for reviews of theory: illustrated by a review of theories linking income and health

BACKGROUND

Review of theory is an area of growing methodological advancement. Theoretical reviews are particularly useful where the literature is complex, multi-discipline, or contested. It has been suggested that adopting methods from systematic reviews may help address these challenges. However, the methodological approaches to reviews of theory, including the degree to which systematic review methods can be incorporated, have received little discussion in the literature. We recently employed systematic review methods in a review of theories about the causal relationship between income and health.

METHODS

This article discusses some of the methodological issues we considered in developing the review and offers lessons learnt from our experiences. It examines the stages of a systematic review in relation to how they could be adapted for a review of theory. The issues arising and the approaches taken in the review of theories in income and health are considered, drawing on the approaches of other reviews of theory.

RESULTS

Different approaches to searching were required, including electronic and manual searches, and electronic citation tracking to follow the development of theories. Determining inclusion criteria was an iterative process to ensure that inclusion criteria were specific enough to make the review practical and focused, but not so narrow that key literature was excluded. Involving subject specialists was valuable in the literature searches to ensure principal papers were identified and during the inductive approaches used in synthesis of theories to provide detailed understanding of how theories related to another. Reviews of theory are likely to involve iterations and inductive processes throughout, and some of the concepts and techniques that have been developed for qualitative evidence synthesis can be usefully translated to theoretical reviews of this kind.

CONCLUSIONS

It may be useful at the outset of a review of theory to consider whether the key aim of the review is to scope out theories relating to a particular issue; to conduct in-depth analysis of key theoretical works with the aim of developing new, overarching theories and interpretations; or to combine both these processes in the review. This can help decide the most appropriate methodological approach to take at particular stages of the review.

Narrative reviews

Although qualitative researches (QR) are invaluable in understanding complex healthcare situations, the quantitative systematic reviews could not treat them. To improve quality of healthcare services, results of QR should be considered in healthcare decision-making processes. Several methods and theories for synthesizing evidences of QR have been developed. In order to activate the narrative reviews and mixed methods reviews in Korean healthcare academies, I arranged the related nomenclatures and suggested some issues to conduct them.

Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review

Interventions to change health-related behaviours typically have modest effects and may be more effective if grounded in appropriate theory. Most theories applied to public health interventions tend to emphasise individual capabilities and motivation, with limited reference to context and social factors. Intervention effectiveness may be increased by drawing on a wider range of theories incorporating social, cultural and economic factors that influence behaviour. The primary aim of this paper is to identify theories of behaviour and behaviour change of potential relevance to public health interventions across four scientific disciplines: psychology, sociology, anthropology and economics. We report in detail the methodology of our scoping review used to identify these theories including which involved a systematic search of electronic databases, consultation with a multidisciplinary advisory group, web searching, searching of reference lists and hand searching of key behavioural science journals. Of secondary interest we developed a list of agreed criteria for judging the quality of the theories. We identified 82 theories and 9 criteria for assessing theory quality. The potential relevance of this wide-ranging number of theories to public health interventions and the ease and usefulness of evaluating the theories in terms of the quality criteria are however yet to be determined.

A repeated cross-sectional study examining the school impact on child weight status

OBJECTIVE

The aim of this study is to examine whether there is a differential impact of primary schools upon children's weight status.

METHODS

A repeated cross-sectional study was undertaken using five years (2006/07-2010/11) of National Child Measurement Programme data, comprising 57,976 children (aged 4-5 (Reception) and 10-11 (Year 6) years) from 300 primary schools across Devon, England. Examining each year separately, the schools were ranked according to their observed and residual (having accounted for school and neighbourhood clustering and pupil ethnicity and socioeconomic status) school mean body mass index standard deviation score (BMI-SDS). Subtracting the Reception from the Year 6 mean residuals gave 'value-added' scores for each school which were also ranked. The rankings were compared within and across the years to assess consistency.

RESULTS

Although pupil BMI-SDS was high, >97% of the variation in BMI-SDS was attributable to environments other than the school. The 'value-added' by each school was only poorly correlated with the observed and residual pupil BMI-SDS; but none of the rankings were consistent across the five years.

CONCLUSION

The inconsistency of the rankings and the small variation in BMI-SDS at the level of the school suggests that there is no systematic differential impact of primary schools upon pupil weight status.

The school environment and student health: a systematic review and meta-ethnography of qualitative research

BACKGROUND

There is increasing interest in promoting young people's health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students' health behaviours, or how students' backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people's health?

METHODS

Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62,329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare's meta-ethnographic approach.

RESULTS

Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people's health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised 'hotspots' at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools' organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of 'escape', either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard's theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people's agency and student-led 'systems' in constituting school environments and generating health risks.

CONCLUSION

Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.

The school environment and student health: a systematic review and meta-ethnography of qualitative research

Background

There is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health?

Methods

Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach.

Results

Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks.

Conclusion

Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.

The effects on student health of interventions modifying the school environment: systematic review

BACKGROUND

Owing to the limited effectiveness of traditional health education curricula in schools, there is increasing interest in interventions aiming to promote young people's health by modifying the school environment. Existing systematic reviews cannot determine whether environmental intervention is effective because they examine interventions combining environmental modifications and traditional health education. This gap is significant because school-environment interventions are complex to implement and may be sidelined in underfunded and attainment-focused school systems without evidence to support such an approach. This systematic review examined the effectiveness of school-environment interventions without health-education components on student health and inequalities.

METHODS

This was a systematic review of experimental/quasi-experimental studies of school-environment interventions. Sixteen databases were searched, eliciting 62 329 references which were screened, with included studies quality assessed, data extracted and narratively synthesised.

RESULTS

Sixteen reports of 10 studies were included, all from the USA and the UK. Five evaluations of interventions aiming to develop a stronger sense of community and/or improve relationships between staff and students suggested potential benefits particularly regarding violence and aggression. Two trials of interventions enabling students to advocate for changes in school catering and physical activity reported benefits for physical activity but not diet. Three evaluations of improvements to school playgrounds offered weak evidence of effects on physical activity.

CONCLUSIONS

School environment interventions show the potential to improve young people's health particularly regarding violence, aggression and physical activity. Further trials are required to provide a stronger and more generalisable evidence base.

Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses

BACKGROUND

The aim of these reviews is to inform the design and content of interventions to reduce obesity in young children. The behaviors that are associated with obesity/overweight have been studied extensively; however, the factors associated with these behaviors in young children (0 to 6 years) have not been systematically reviewed. Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood. In order to develop effective interventions and change behavior, it is important to understand the factors that are associated with those behaviors. For example, we need to understand whether it would be more important to target the family, childcare settings or the wider environment and identify the most effective way of changing these energy balance related behaviors.

METHODS/DESIGN

Quantitative (intervention and observational) and qualitative literature on determinants/correlates of fruit and vegetable intake, sugar sweetened beverage and other unhealthy diet intake, and physical activity and sedentary behaviors in young children will be systematically identified, mapped and reviewed. A common search strategy (no language or period restrictions) will be used to identify papers from eight electronic databases and this will be supplemented by hand-searching. Next, studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years (at baseline) will be screened and mapped descriptively followed by in-depth data extraction, quality assessment and synthesis. Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis, and qualitative studies using thematic analysis. Qualitative evidence will be integrated with the quantitative evidence, using a parallel synthesis approach, to provide a deeper understanding of effective strategies to influence these energy balance related behaviors.

DISCUSSION

In addition to updating and mapping current research, these reviews will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group (0 to 6 years) with the aim of informing future interventions.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) Registration number: CRD42012002881.

The effects of the school environment on student health: a systematic review of multi-level studies

Health outcomes vary between schools and it is theorised that this may be partly attributable to variation in the school environment. Existing systematic reviews have not drawn authoritative conclusions because of methodological limitations in the review or studies available. We identified 42 multi-level studies, ten of which were judged of sufficient quality to narratively synthesize. There was consistent evidence that schools with higher attainment and attendance than would be expected from student intake had lower rates of substance use. Findings on the influence of smoking/alcohol policies were mixed. Three studies examined the health effects variously associated with school campus area and observability, year structure, school size and pupil-to-teacher ratio with mixed findings. The studies reviewed support the potential influence of the school environment on student health.

Implementing health promotion in schools: protocol for a realist systematic review of research and experience in the United Kingdom (UK)

BACKGROUND

School-based interventions and campaigns are used to promote health and address a wide variety of public health problems. Schools are considered to be key sites for the implementation of health promotion programmes for their potential to reach the whole population in particular age-groups and instil healthy patterns of behavior early in life. However, evidence for the effectiveness of school-based health promotion interventions is highly variable. Systematic reviews of the evidence of school-based interventions tend to be highly problem- or intervention- specific, thereby missing potential generic insights into implementation and effectiveness of such programmes across problems.

METHODS/DESIGN

A realist systematic review will be undertaken to explain how, why and in what circumstances schools can provide feasible settings for effective health promotion programmes in the United Kingdom (UK). The review will be conducted in two phases. Phase 1 will identify programme theories about implementation (ideas about what enables or inhibits effective health promotion to be delivered in a school setting). Phase 2 will test the programme theories so that they can be challenged, endorsed and/or refined. A Review Advisory Group of education and health professionals will be convened to help identify and choose potential programme theories, provide a 'reality check' on the clarity and explanatory strength of the mechanisms to be tested, and help shape the presentation of findings to be usable by practitioners and decision-makers. Review findings will be disseminated through liaison with decision-makers, and voluntary and professional groups in the fields of education and health.