A whole-school approach to promoting health in schools: Evidence that it can work
The best days of your life or seemingly endless hours of boredom and torture? Whatever your opinion on school, the fact is that children and young people spend a huge proportion of their lives in this setting.
Given this, from a public health perspective, it makes sense to make schools as healthy as possible. Attitudes, beliefs and (most importantly) behaviours learned during these early years show a strong tendency to continue into adulthood, so establishing healthy habits during these formative years is a key public health priority. Healthy, happy students are obviously important for teachers too: healthy children also achieve better results at school. So it’s a win-win situation for health and education alike. But how to achieve this?
What is a health promoting school?
Traditional health education approaches that just promoted health messages (such as not smoking or eating healthily) through the school curriculum have produced largely disappointing results, with little evidence of sustained changes in student health behaviours. Recognising this, a new holistic approach to school health promotion was developed in the late 1980s, which sought to promote health through the whole school environment and not just through ‘health education’ in the curriculum. This new ‘Health Promoting Schools’ (HPS) framework required action in three areas:
Formal health curriculum
Health education topics are given specific time allocation within the formal school curriculum in order to help students develop the knowledge, attitudes, and skills needed for healthy choices. For example, programmes might emphasise the importance of getting your ‘5 A DAY’ or focus on developing communication skills and refusal techniques to reduce smoking rates.
Ethos and environment of the school
Health and well-being of students and staff are promoted through the ‘hidden’ or ‘informal’ curriculum, which encompasses the values and attitudes promoted within the school, and the physical environment and setting of the school. Examples might include serving healthier food in school canteens, providing secure cycle parking to promote active transport, or setting up peer buddying systems to reduce bullying.
Engagement with families and/or communities
Schools seek to engage with families, outside agencies, and the wider community in recognition of the importance of these other spheres of influence on children’s attitudes and behaviours. This might include setting family homework assignments to raise awareness of health messages at home, inviting parents to training sessions or inviting local sports clubs into schools to speak to students and encourage participation.
Reviewing the HPS approach
But does this approach actually improve health and health behaviours in students? Researchers at DECIPHer, in collaboration with international experts, set out to review the best evidence available worldwide to determine the effectiveness of the ‘Health Promoting Schools’ approach.
For our review of the WHO’s Health Promoting Schools framework, we conducted a Cochrane systematic review, the ‘gold standard’ method for reviewing intervention effectiveness. We searched 20 health, education and social science databases, and trials registries and relevant websites, to find cluster randomised controlled trials that used this HPS approach. To be included in the review, interventions had to target all three HPS areas (curriculum, ethos/environment and family/community) and include students aged 4-18 years.
From the 48,551 records retrieved, we identified 67 trials that met our inclusion criteria. These 67 studies focused on interventions concerned with a wide range of health topics including physical activity, nutrition, substance use (tobacco, alcohol, drugs), bullying, violence, mental health, sexual health, hand-washing, cycle-helmet use, sun protection, eating disorders and oral health. Very few studies, however, measured the impact on their intervention on students’ attendance or academic achievement.
Is the HPS approach effective?
We found that interventions using the HPS approach were effective for the following important health outcomes:
- body mass index (BMI)
- physical activity and fitness
- fruit and vegetable intake
- cigarette use
- being bullied.
We did not find strong evidence of impact on other outcomes (BMI when gender and age were taken into account, fat intake, alcohol and drug use, violence, mental health, and bullying others). However, in most cases very few studies provided data on these outcomes so the effectiveness of the HPS approach for these remains unclear. The evidence for certain outcomes (such as violence and alcohol/drug use) suggests the HPS approach may be able to reduce these behaviours but more data are needed before we can draw clear conclusions. For several other outcomes (sexual health, hand-washing, cycle-helmet use, sun protection, eating disorders, oral health and academic/attendance outcomes) there were so few studies we cannot yet tell if this approach is effective.
While other reviews have evaluated the HPS framework, this is the first study that includes only data from randomised controlled trials – the most rigorous study design for assessing intervention effectiveness. Using only these rigorous studies, we have found evidence that this type of health promotion in schools can play an important part in tackling some of the biggest public health challenges, such as obesity and tobacco use. It is disappointing to note, however, that so few studies measured the impact of their intervention on academic outcomes. School health interventions are far more likely to be successful if teachers can see the value in them. One of the clear messages from our review, therefore, is that we in public health need to get much better at seeing the connections between health and education and start measuring academic as well as health outcomes in our intervention.
This piece summarises: Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, Komro KA, Gibbs LF, Magnus D, Campbell R. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008958. DOI: 10.1002/14651858.CD008958.pub2.
Dr. Beki Langford is a research associate at the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) , based at the University of Bristol. She tweets at @BekiLangford.