Abstract

Assessed as up to date: 2013/09/15

Background

The World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.

We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Author(s)

Langford Rebecca, Bonell Christopher P, Jones Hayley E, Pouliou Theodora, Murphy Simon M, Waters Elizabeth, Komro Kelli A, Gibbs Lisa F, Magnus Daniel, Campbell Rona

Summary

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

Background

Health and education are strongly connected: healthy children achieve better results at school, which in turn are associated with improved health later in life. This relationship between health and education forms the basis of the World Health Organization's (WHO’s) Health Promoting Schools (HPS) framework, an approach to promoting health in schools that addresses the whole school environment. Although the HPS framework is used in many schools, we currently do not know if it is effective. This review aimed to assess whether the HPS framework can improve students’ health and well-being and their performance at school.

Study characteristics

We searched 20 health, education, and social science databases, as well as trials registries and relevant websites, for cluster-randomised controlled trials of school-based interventions aiming to improve the health of young people aged four to 18 years. We only included trials of programmes that addressed all three points in the HPS framework: including health education in the curriculum; changing the school’s social or physical environment, or both; and involving students’ families or the local community, or both.

Key results

We found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand-washing, cycle-helmet use, sun protection, eating disorders, and oral health. For each study, two review authors independently extracted relevant data and assessed the risk of the study being biased. We grouped together studies according to the health topic(s) they focused on.

We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand-washing, cycle-helmet use, eating disorders, sun protection, oral health or academic outcomes. Few studies discussed whether the health promotion activities, or the collection of data relating to these, could have caused any harm to the students involved.

Quality of the evidence

Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general.

Conclusions

Overall, we found some evidence to suggest the HPS approach can produce improvements in certain areas of health, but there are not enough data to draw conclusions about its effectiveness for others. We need more studies to find out if this approach can improve other aspects of health and how students perform at school.

Reviewer's Conclusions

Implications for practice

This review provides evidence that a holistic school-based intervention, like the Health Promoting Schools framework, can be effective at improving a number of health outcomes in students, especially those concerning body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. On current evidence, we are unable to determine the impact of this holistic approach on other health outcomes such as alcohol and drug use, sexual health, violence, and mental health. However, on balance, there is currently little to suggest that the interventions that have targeted these health outcomes are likely to cause harm in student populations. Given the paucity of data, it is not possible to determine the impact of the HPS approach on academic or attendance or both outcomes.

Child and adolescent health matter. Investment in these formative years can prevent suffering, reduce inequity, create healthy and productive adults, and deliver social and economic dividends to nations. Schools are an obvious place to facilitate this investment, given the inextricable links between health and education. Ultimately the aim of these two disciplines is largely the same: to create healthy, well-educated individuals who can contribute successfully to society.

Despite the obvious connections, across the globe, structural barriers prevent the realisation of this mutual agenda. Government departments responsible for health and education often operate in isolation from one another, and this fundamental connection is lost. The World Health Organization (WHO) explicitly set out a new vision of health and education in its Health Promoting Schools (HPS) framework, yet since its inception there appears to have been little advance in breaking down this silo approach. Our review demonstrates the potential benefits of this approach for health. We have yet to see its benefit for education. This is a political issue. Cross-departmental working between health and education is required to allow the HPS policy to achieve its potential.

Implications for research

While this review has produced some evidence in favour of the HPS framework, the number of studies contributing evidence is low, hampering our ability to draw definitive conclusions. We regard this review as an important first step in mapping out the broad range of intervention types using the HPS approach and a synthesis of the current state of evidence. More research in this area is justified and we have identified a number of research gaps below, which future studies should seek to fill. In addition, we have highlighted some methodological and reporting issues, which should be addressed.

Research gaps:

• More research is required to determine the effectiveness of the HPS approach, particularly with regard to sexual health, mental health, alcohol and drug use, and violence (either singly or as part of a multiple risk behaviour intervention). Research should seek to determine whether these outcomes are best addressed during childhood or adolescence.
• More evaluations of physical activity or nutrition interventions or both are required that target older children (over 12 years of age).
• Future interventions should attempt to measure their impact on academic achievement and behaviours, in addition to health outcomes. The most appropriate ways to assess these should be determined in close consultation with teachers and educators.
• There is a need for more research conducted outside of the United States, particularly with regard to multiple risk behaviour interventions.
• High-quality randomised controlled trials (RCTs), using the HPS approach, conducted in low- and middle-income countries are also urgently needed.

Methodological issues:

• Future interventions might consider the use of factorial designs to identify the importance of the three different intervention levels (curriculum, ethos or environment or both, and family or community or both) and how they interact.
• Interventions should be theory-based and have a clear implementation plan, preferably detailed in a logic model to facilitate evaluation and reporting of process and outcomes. Mediation analysis should be used to test whether or not the intervention changed hypothesised mediators, and whether changes in mediators resulted in changes in outcomes.
• Process evaluations should be embedded in trial evaluations and seek to use consistent measures to assess implementation fidelity, acceptance, and reach. However, they also need to go beyond these by collecting qualitative contextual data, which will help answer the questions: what works, for whom, in what circumstances, and why (Bonell 2012).
• Studies should include economic evaluations so that the cost effectiveness of this approach can be determined.
• Studies focusing on overweight or obesity should use age- and gender-adjusted BMI scores (standardised BMI (zBMI)).
• Studies should use validated, objective outcome measures wherever possible; for example, accelerometry to measure physical activity, cotinine tests to assess smoking status.
• Interventions should include postintervention follow-up measures in order to determine the sustainability of the HPS approach.

Reporting issues:

• Authors should adhere to the CONSORT extension guidelines for the reporting for cluster-RCTs (Campbell 2004). In particular, trial papers should report school-level intra-cluster correlation coefficients (ICCs) on all relevant outcomes.
• Descriptive statistics (for example, means and standard deviations) should be provided in addition to any multi-level model data to allow easy inclusion of data in future meta-analyses.