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Research Article

Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews

Roles Formal analysis, Methodology, Writing – original draft

Affiliation Institute for Medical Informatics, Biometrics and Epidemiology, Ludwig-Maximilians-Universität (LMU) Munich, Munich, Bavaria, Germany

Roles Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland

Roles Methodology, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

* E-mail: [email protected]

• Julia Levinson, 
• Kid Kohl, 
• Valentina Baltag, 
• David Anthony Ross

• Published: June 12, 2019
• https://doi.org/10.1371/journal.pone.0212603
• Reader Comments

Schools are the only institution regularly reaching the majority of school-age children and adolescents across the globe. Although at least 102 countries have school health services, there is no rigorous, evidence-based guidance on which school health services are effective and should be implemented in schools. To investigate the effectiveness of school health services for improving the health of school-age children and adolescents, a systematic review of systematic reviews (overview) was conducted. Five databases were searched through June 2018. Systematic reviews of intervention studies that evaluated school-based or school-linked health services delivered by a health provider were included. Review quality was assessed using a modified Ballard and Montgomery four-item checklist. 1654 references were screened and 20 systematic reviews containing 270 primary studies were assessed narratively. Interventions with evidence for effectiveness addressed autism, depression, anxiety, obesity, dental caries, visual acuity, asthma, and sleep. No review evaluated the effectiveness of a multi-component school health services intervention addressing multiple health areas. From the limited amount of information available in existing systematic reviews, the strongest evidence supports implementation of anxiety prevention programs, indicated asthma education, and vision screening with provision of free spectacles. Additional systematic reviews are needed that analyze the effectiveness of comprehensive school health services, and specific services for under-researched health areas relevant for this population.

Citation: Levinson J, Kohl K, Baltag V, Ross DA (2019) Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews. PLoS ONE 14(6): e0212603. https://doi.org/10.1371/journal.pone.0212603

Editor: Danuta Wasserman, Karolinska Institutet, SWEDEN

Received: February 5, 2019; Accepted: May 27, 2019; Published: June 12, 2019

Copyright: © 2019 Levinson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The World Health Organization (WHO) launched the Global School Health Initiative in 1995 with the goal to improve child, adolescent and community health through health promotion and programming in schools [ 1 ]. This initiative is dedicated to promoting development of school health programs and increasing the number of health-promoting schools, characterized by WHO as “a school constantly strengthening its capacity as a healthy setting for living, learning and working” [ 1 ]. In 2000, WHO, the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Children's Fund (UNICEF) and the World Bank developed a partnership for Focusing Resources on Effective School Health–a FRESH Start approach [ 2 ]. The FRESH framework promotes four pillars: health-related school policies, provision of safe water and sanitation, skills-based health education and school-based health and nutrition services [ 2 ]. While various guidance documents have been published by United Nations (UN) organizations addressing a range of services from oral health to malaria [ 3 – 7 ], there is no internationally accepted guideline regarding school health services. This systematic review of systematic reviews, henceforth referred to as an overview, will inform the upcoming development of a WHO guideline that addresses the school health services component of health-promoting schools and feeds into the FRESH framework. This overview and the upcoming WHO guideline will specifically address school health services delivered by health providers.

Schools offer a unique platform for health care delivery. In 2015, the global means for the primary and secondary net school enrollment rates were 90% and 65%, respectively, thus the potential reach of school health services is wide [ 8 ]. Additionally, a recent review found that school-based or school-linked health services already exist in at least 102 countries [ 9 ]. The 2017 Global Accelerated Action for the Health of Adolescents (AA-HA!) implementation guidance calls for the prioritization of school health programs as an important step towards universal health coverage and urges that “Every school should be a health promoting school” [ 10 ].

The primary objective of this overview was to explore the effectiveness of school-based or school-linked health services delivered by a health provider for improving the health of school-age children and adolescents. Through a comprehensive literature search, the overview aimed to identify health areas and specific school health service interventions that have at least some evidence of effectiveness. It was also designed to suggest further research in areas where recent systematic reviews (SRs) exist, but with insufficient evidence. Finally, the overview aimed to identify the health areas and specific school health services interventions for which no SRs were found, whether because the primary literature does not exist or where there are primary studies but no SR has been conducted.

This overview was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) [ 11 ]. A protocol was developed a priori that outlined the overview objectives, aims, operational definitions, search strategy, inclusion/exclusion criteria, and quality appraisal methods. This document was followed throughout the review process and is available in S1 Appendix .

Search strategy

PubMed, Web of Science, ERIC, PsycINFO, and the Cochrane Library were searched systematically. A detailed search strategy was iteratively developed in consultation with a librarian experienced in SRs and an expert in school health services. The search strategy was developed for PubMed and then adapted for the other four databases. The search strategy is presented in S2 Appendix . Searches were performed on June 15, 2018. Any existing overviews or SRs of SRs that emerged from the searches were not themselves included, but the SRs within them were extracted and screened. Additionally, reference lists of included articles were scanned for any relevant SRs.

Eligibility criteria

SRs were included in this overview if at least 50% of the studies within the SR fulfilled the following criteria: (a) participants were children (ages 5–9) or adolescents (ages 10–19) enrolled in schools; (b) interventions were school-based or school-linked health services, involved a health provider (see definitions in S1 Appendix ), and were of any duration or length of follow-up; (c) intervention effectiveness was compared to either no intervention, an alternative intervention, the same intervention in a different setting (i.e. not in schools), an active control, or a waitlist control; (d) interventions aimed to improve one or more health outcomes, as defined by the SR authors; and (e) study designs were either randomized controlled trials (RCTs), quasi-experimental studies (QEs), or other non-randomized intervention studies. There were no date restrictions on publication of included SRs. In addition to these criteria for included studies, the SRs themselves had to fulfill the following criteria: (a) included the words “systematic review” in the title or abstract; (b) outlined inclusion criteria within the methods section; (c) published in peer-reviewed journals and indexed before June 15, 2018; (d) published in the English language. In addition to SRs that did not meet these inclusion criteria, SRs were excluded if the review was superseded by a newer version.

Study selection

Citations identified from the systematic search were uploaded to Covidence systematic review software [ 12 ] and duplicates were automatically deleted. Two reviewers (KK and JL) screened all titles and abstracts using the inclusion/exclusion criteria and excluded all articles that were definitely ineligible. Articles that received conflicting votes (ineligible vs. potentially or probably eligible) were discussed and consensus was reached. The same two reviewers screened the full text of all the potentially or probably eligible articles using a ranked list of the inclusion criteria ( S1 Appendix ). Reasons for exclusion were selected from the ranked list. If consensus was not possible during title/abstract or full text screening, a third reviewer (DR), who had the casting vote, would have been asked to independently screen the article. This was never required as consensus was always reached.

Data collection

One reviewer (JL) extracted summary data from each selected article using a customized standard form with independent data extraction performed for 15% of included SRs by one of the other reviewers (DR or KK). There was 92% agreement between reviewers for all items within the standard form, with discrepancies only in level of detail. Data items included the research design of the SR and primary studies, sample description and setting, intervention characteristics, outcomes, meta-analysis results, quality appraisal, and conclusions.

Synthesis of results

Due to the heterogeneity of the SRs included in this overview, it was not possible to perform a meta-analysis. Outcome measures were collected from included studies.

Risk of bias

Risk of bias within primary studies was recorded in Table B in S4 Appendix . Risk of bias across SRs was determined using Ballard and Montgomery’s four-item checklist for overviews of SRs [ 13 ]. These items include: (1) overlap (see below), (2) rating of confidence from the AMSTAR 2 checklist [ 14 ], (3) date of publication, and (4) match between the scope of the included SRs and the overview itself.

The AMSTAR 2 checklist [ 17 ] was used to appraise quality of included SRs. One reviewer (JL) assessed all SRs and a second (KK) duplicated appraisal of 10%, with 94% agreement and only minor disagreements that did not impact grades of confidence. Following the recommendation of the AMSTAR 2 developers [ 17 ], individual ratings were not combined into an overall score. Instead, the authors determined which of the 16 items on the checklist were critical for this overview and which of the items were non-critical. Building on a method suggested by Shea and colleagues [ 17 ], grades of confidence in the results of each SR were generated based on critical flaws and non-critical weaknesses. The grading system is available in Tables E and F in S6 Appendix . Confidence in results ranged from high (three or fewer non-critical weaknesses) to critically low (more than three critical flaws with or without non-critical weaknesses) [ 17 ].

The final two items in the four-item checklist are (3) date of publication to ensure that results are up-to-date, and (4) matching of the scope to confirm that primary studies within SRs are relevant to the overview. This overview considered SRs published in 2016, 2017, or 2018 to be up-to-date. Although all SRs were included if at least 50% of the primary studies within them fulfilled all inclusion criteria, SRs where closer to 100% of primary studies fulfilled all criteria were considered to be better matched than those with closer to 50%.

Results of the search

1720 references were identified from the systematic literature search. 570 were duplicates, leaving 1150 titles and abstracts to be screened. After removal of 705 articles with definitely ineligible titles/abstracts, 445 full text articles were screened using the ranked inclusion/exclusion criteria ( S1 Appendix ). 425 of these articles were ineligible. The most common reasons for exclusion were, first, if at least 50% of studies included within a SR were unclear for at least one criterion (e.g. unclear if a health provider was involved), followed by if less than 50% of studies within a SR fulfilled all inclusion criteria. These reasons for exclusion applied to 183 and 126 SRs, respectively. The full list of the specific reasons for exclusion of full texts is available in Table A within S3 Appendix . Fig 1 displays the PRISMA flowchart for the search. S7 Appendix gives the PRISMA checklist that was used.

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https://doi.org/10.1371/journal.pone.0212603.g001

Characteristics of included systematic reviews

20 SRs fulfilled all inclusion criteria and were included in this overview. These SRs contained 270 primary studies, 225 of which were unique and 45 were included in more than one SR. The SRs were written in English and published between 2006 and 2018. Primary studies included within the SRs were published between 1967 and 2017. Eleven of the SRs used meta-analysis to combine results [ 18 – 28 ], whereas the remaining nine SRs narratively synthesized results [ 29 – 37 ]. Eleven SRs included studies located in countries with high-income or upper-middle income economies only [ 19 , 20 , 23 – 25 , 29 – 33 , 37 , 38 , 39 ]. Six SRs included at least one study from countries with lower-middle income or lower income economies [ 18 , 21 , 22 , 28 , 35 , 36 ]. The final three SRs either did not state the locations of included studies [ 27 , 34 ] or provided regions rather than specific country locations [ 26 ].

To be included in this overview, at least 50% of studies within each SR had to fulfill all inclusion criteria. In four SRs, 100% of included studies fulfilled all inclusion criteria [ 18 , 27 , 29 , 33 ], although Brendel and colleagues [ 29 ] only included one study in total. In another four SRs, 75% to 99% of included studies fulfilled all the inclusion criteria [ 21 , 26 , 30 , 37 ]. In the remaining twelve SRs, 50% to 74% of included studies fulfilled all the inclusion criteria [ 19 , 20 , 22 – 25 , 28 , 31 , 32 , 34 – 36 ].

All SRs primarily examined studies on school-based, rather than school-linked interventions. The 20 SRs covered eight health areas: nine on mental health [ 19 , 23 , 24 , 28 , 29 , 32 – 34 , 36 ], four on oral health [ 18 , 25 , 27 , 30 ], two on asthma [ 31 , 37 ], and one SR each on sleep [ 20 ]; obesity [ 26 ]; vision [ 21 ]; menstrual management [ 22 ]; and sexual and reproductive health (SRH) [ 35 ]. Eleven SRs included only cluster- and individually-randomized controlled trials [ 19 – 21 , 24 , 27 , 28 , 30 , 32 , 34 , 37 ], seven SRs included other types of controlled and uncontrolled experimental studies in addition to RCTs [ 22 , 25 , 26 , 31 , 33 , 35 , 36 ], and two SRs included only QEs [ 29 ] or controlled clinical trials [ 23 ]. Table 1 summarizes the characteristics of the 20 included SRs.

https://doi.org/10.1371/journal.pone.0212603.t001

Quality appraisal of systematic reviews within this overview

The corrected covered area (CCA) was found to be 1, indicating only slight overlap between the 20 SRs. Calculations for the CCA can be found in Tables C and D in S5 Appendix . Table 2 presents the remaining three of the four items of Ballard and Montgomery’s checklist for overviews of reviews: (2) levels of confidence in results for each included SR, (3) publication year, and (4) match in scope to the overview. A majority of the studies (80%) were given low or critically low levels of confidence. Only three SRs [ 18 , 21 , 25 ] were scored as having moderate levels of confidence and just one [ 30 ] was given a high level of confidence. The details of the quality appraisal of primary studies included in the SRs are given in Table B in S4 Appendix .

https://doi.org/10.1371/journal.pone.0212603.t002

Findings: Comprehensive, multi-component, or multi-health area services

None of the SRs evaluated comprehensive, multi-component, or multi-health area school health services.

Findings: Asthma interventions

Two SRs found evidence for the potential effectiveness of educational interventions for children and adolescents with asthma diagnoses ( Table 3A ) [ 31 , 37 ]. Geryk and colleagues found that education on correct use of an inhaler improved inhaler technique, regardless of deliverer, method, or duration of the intervention [ 31 ]. However, they did not assess risk of bias or appraise the quality of included studies [ 31 ]. Walter and colleagues found that family asthma educational programs for children and their parents or caregivers improved quality of life for both caregivers and children, and decreased asthma exacerbations for children [ 37 ]. While results from primary studies were statistically significant in both SRs, heterogeneity of interventions precluded meta-analysis by Walter and colleagues [ 37 ] and no reason was given for why meta-analysis was not performed by Geryk and colleagues [ 31 ].

https://doi.org/10.1371/journal.pone.0212603.t003

Findings: Menstrual management interventions

Hennegan and Montgomery assessed the effectiveness of “hardware” and “software” menstrual management interventions ( Table 3B ) [ 22 ]. Hardware interventions included provision of sanitary products and software interventions focused on menstrual management education. A meta-analysis of two studies on sanitary pad provision found a moderate but statistically non-significant effect on school attendance. However, it was unclear whether these studies involved a health provider [ 22 ]. Outcomes across studies differed, but the authors noted trends toward improvement in menstruation knowledge, management practices, psychosocial outcomes, and school attendance. Hennegan and Montgomery found a high level of heterogeneity and substantial risk of bias in the included studies overall, thus they were unable to make conclusions about the effectiveness of menstrual management interventions [ 22 ].

Findings: Mental health interventions

The effectiveness of school-based mental health services was assessed in nine SRs ( Table 3C ) [ 19 , 23 , 24 , 28 , 29 , 32 – 34 , 36 , 39 ]. SRs addressed various intervention types: universal interventions [ 19 , 24 , 28 , 32 , 34 , 39 ]; targeted interventions for military-connected children [ 29 ], children and adolescents at risk for depression and/or anxiety [ 28 , 34 ], refugee and war-traumatized youth [ 36 ], and children referred to therapy [ 33 ]; and indicated interventions for children and/or adolescents diagnosed with autism spectrum disorder [ 23 ], depression [ 24 , 28 , 39 ], or anxiety [ 24 , 34 , 39 ].

Prevention and treatment of mood disorders was assessed in five SRs, all of which targeted children and adolescents using RCTs of established programs. Higgins and O’Sullivan assessed the FRIENDS for Life program, a manual-based cognitive behavioral anxiety prevention program comprised of ten sessions with developmentally-tailored programs for different age groups [ 32 ]. They found statistically significant improvements in self-reported measures of anxiety for participants who completed the program as compared to those in the control group [ 32 ]. A SR and meta-analysis by Bastounis and colleagues on the educational and preventative Penn Resiliency Program (PRP) and its derivatives found small, non-significant effect sizes for the prevalence of both depression and anxiety, favoring the intervention in the former and the control in the latter [ 19 ]. The remaining three SRs also assessed FRIENDS and PRP along with additional often-overlapping programs. Neil and Christensen analyzed 21 unique anxiety prevention and early intervention programs and found reductions in anxiety symptoms in 78% of the included studies [ 34 ]. Kavanagh and colleagues examined depression and anxiety group counseling programs based on cognitive behavioral therapy (CBT) and found statistically significant reductions of depressive symptoms at both four weeks and three months follow-up [ 24 , 39 ]. Finally, meta-analysis by Werner-Seidler and colleagues of 81 RCTs on the effectiveness of depression and anxiety prevention and group therapy programs found small yet statistically significant effect sizes in favor of the intervention groups for both depression and anxiety as compared to control groups [ 28 ]. Although the overall degree of overlap between all SRs within this overview was slight, the overlap between just these five SRs targeting mood disorders was high (CCA = 11).

Assessments of music [ 23 ] and art therapy [ 33 ] in two SRs reported weak evidence of effectiveness. Gold and colleagues assessed daily music therapy as an intervention to improve verbal and gestural communicative skills and reduce behavioral problems in children diagnosed with autism spectrum disorder [ 23 ]. Meta-analysis found small but statistically significant effect sizes in favor of music therapy for gestural communication, verbal communication, and behavioral problems [ 23 ]. McDonald and Drey narratively assessed group-based art therapy as an intervention for children with Oppositional Defiant Disorder (ODD), Separation Anxiety Disorder (SAD), moderate to severe behavior problems, or learning disorders [ 33 ]. The authors found improvements in classroom behavior, symptoms of ODD, and symptoms of SAD [ 33 ]. However, in the studies included in both Gold and colleagues’ and McDonald and Drey’s SRs, the numbers of participants per intervention group were very small: 4–10 and 12–25 per study, respectively, introducing possibility of bias [ 23 , 33 ].

Mostly favorable evidence of effectiveness was found in a SR of social-emotional interventions for refugee and war-traumatized youth from 26 countries [ 36 ]. Improvements in trauma-related symptoms and impairment were found through narrative assessment of creative expression interventions, cognitive behavioral interventions, and multifaceted interventions [ 36 ]. In contrast with Gold and colleagues [ 23 ], this SR by Sullivan and Simonson found negative effects from music therapy interventions [ 36 ]. However, there was no risk of bias assessment in this SR and therefore the results must be interpreted cautiously.

The final SR on mental health services examined well-being interventions for children with a parent in the military [ 29 ]. Only one quasi-experimental study from the United States in 1999 was included in the SR. The study assessed a group counseling intervention and found no statistically significant effects on the prevalence of anxiety, self-esteem, internalizing behavior or externalizing behavior [ 29 ].

Findings: Obesity interventions

Schroeder and colleagues reviewed the effectiveness of obesity treatment and prevention interventions that specifically involved a school nurse ( Table 3D ) [ 26 ]. Most interventions involved school-nurse-delivered nutrition counseling, nutrition and health education, and some parent involvement or physical activity. Meta-analysis indicated small, yet statistically significant, reductions in body mass index (BMI), BMI z-score, and BMI percentile for both obesity treatment and prevention [ 26 ].

Findings: Oral health interventions

SRs on oral health interventions focused on prevention [ 25 , 30 ], screening [ 18 ], and education [ 27 , 30 ] ( Table 3E ). Strongest evidence in favor of oral health interventions emerged from a SR on universal topical application of fluoride gel for the prevention of dental caries [ 25 ]. Meta-analysis results indicated a statistically significant effect on the before-after change in caries prevalence [ 25 ]. A universal educational intervention on oral hygiene and caries produced weaker evidence of effectiveness [ 27 ]. Small but statistically significant effect sizes were found in favor of the intervention for mean plaque levels and oral hygiene, but no statistical significance was found for change in gingivitis indices [ 27 ].

Two SRs on dental health screening [ 18 ] and behavioral interventions for caries prevention [ 30 ] found limited evidence of effectiveness. Arora and colleagues did not find any RCTs that looked at the effectiveness of dental health screening versus no screening on improving oral health outcomes, but their search did locate six RCTs from the United Kingdom and India with dental care attendance as the outcome [ 18 ]. The data was too heterogeneous to meta-analyze, and the authors determined that the certainty of the evidence of the benefit of dental screening in increasing dental attendance was very low [ 18 ]. The other SR examined behavioral interventions in the form of education on tooth brushing and the use of fluoride toothpaste in Brazil, Italy, United Kingdom, and Iran [ 30 ]. Due to the diversity in outcome measures and intervention intensities, the authors felt unable to make any evidence-based recommendations [ 30 ].

Findings: Sexual and reproductive health interventions

A SR on sexual health interventions for prevention of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) in sub-Saharan African countries found that educational interventions were successful in increasing knowledge and attitudes for participants ( Table 3F ) [ 35 ]. However, the SR suggested that the studies were ineffective in changing self-reported risky behaviors, although follow-up was either immediate or short-term (less than 6 months) [ 35 ]. This SR did not discuss the quality or risk of bias of included studies [ 35 ].

Findings: Sleep interventions

Chung and colleagues systematically reviewed and meta-analyzed universal sleep education programs as compared to no additional sleep intervention from Australia, New Zealand, Brazil, and Hong Kong ( Table 3G ) [ 20 ]. Five of the included studies examined the same weekly sleep education program from the Australian Centre for Education in Sleep. The sixth study assessed a 4-day program in Brazil. Meta-analysis of the six studies showed statistically significant short-term benefits for weekday sleep time, weekend sleep time, and mood [ 20 ]. However, these results did not persist at follow-up [ 20 ].

Findings: Vision interventions

Evans and colleagues reviewed seven RCTs from China, India, and Tanzania on vision screening for correctable visual acuity deficits at or before school entry ( Table 3H ) [ 21 ]. Through meta-analysis of two RCTs, the authors found that school vision screening combined with provision of free spectacles resulted in a statistically significant 60% increase in the wearing of spectacles at 3–8 months follow-up as compared to vision screening combined with prescription for spectacles only [ 21 ]. Evans and colleagues found no statistically significant difference in the proportion of students wearing spectacles at 1–4 months follow-up between vision screening with provision of ready-made spectacles and vision screening with provision of custom-made spectacles in a meta-analysis of three RCTs [ 21 ]. Education on the wearing of spectacles in addition to vision screening as compared to vision screening alone did not have a significant effect [ 21 ]. No SRs found eligible studies comparing vision screening with no vision screening.

Summary of key findings

This overview found 20 SRs covering 270 primary studies. The majority of SRs assessed educational, counseling, or preventive interventions, most of which were special research interventions rather than routinely-delivered school health services. No SR examined comprehensive or multi-component school health services, despite the fact that comprehensive services may be more efficient, easier to implement, and more sustainable than single interventions [ 40 ]. It is unclear if this finding indicates a lack of primary studies on comprehensive or multi-component school health services, or if primary studies do exist but no SR has been conducted. Results from this overview suggest that certain interventions can be effective in improving child and adolescent health outcomes, and thus may be worthwhile for integration into school health programs.

Effectiveness of specific interventions

Vision screening is one of the most common forms of school health services [ 9 ], although the majority of programs are concentrated in high-income countries (HIC) [ 21 ]. Although prevalence of visual impairment varies widely by ethnic group and age [ 41 ], WHO estimates that at least 19 million children below age 15 are visually impaired [ 42 ]. Evans and colleagues found strong evidence from China, Tanzania, and India that school vision screening for correctable visual acuity deficits increased wearing of spectacles when spectacles were provided at no cost [ 21 ]. A recent guideline from the International Agency for Prevention of Blindness (IAPB) reiterates the importance of free spectacles and goes further to suggest that low- and middle-income countries (LMIC) adopt comprehensive school eye health programs [ 43 ]. Vision screening linked with free provision of spectacles, as a component of a comprehensive school eye health program, is an example of a cost-effective form of school health services that may be implemented.

Five SRs covered depression and/or anxiety prevention and early intervention programs, with the FRIENDS for Life program (FRIENDS) and the Penn Resiliency Program (PRP) most common [ 19 , 24 , 28 , 32 , 34 ]. Given that FRIENDS has been endorsed by WHO [ 44 ] and was found to be effective in decreasing anxiety symptoms in all four SRs where it was mentioned in this overview [ 28 , 32 , 34 , 39 ], policy makers and school health officials may consider incorporating this or similar programs into existing school health services. However, it should be noted that these SRs found mixed evidence of maintenance of effects over time [ 28 , 32 , 34 , 39 ]. The four SRs that included PRP found mixed evidence [ 34 ] or no evidence of effectiveness [ 19 , 24 , 28 , 39 ], bringing the popularity of this intervention into question. Finally, creative therapy interventions seem to be effective for indicated populations of school-age children, such as children with autism spectrum disorder [ 23 , 33 ]. However, this conclusion should be interpreted cautiously due to small effect sizes, small sample sizes, and conflicting evidence on the effectiveness of music therapy between Sullivan and Simonson [ 36 ] and Gold and colleagues [ 23 ].

Comprehensive school programs that promote healthy school environments, health and nutrition literacy, and physical activity are one of the six key areas for ending childhood obesity recommended by WHO [ 45 ]. This overview found only one SR that assessed obesity treatment and prevention delivered by a health professional in schools, despite the fact that over 340 million school-age children and adolescents were overweight or obese in 2016 [ 46 ]. Schroeder and colleagues found that school nurses are well positioned to deliver nutritional counseling, design and coordinate physical activity interventions, and educate parents, students, and staff on health, nutrition, and fitness [ 26 ]. However, all included primary studies were delivered in HIC [ 26 ].

Schools are considered to be an ideal platform for oral health promotion through education, services, and the school environment [ 6 ]. The most promising evidence from a SR was on topical application of fluoride gel for the prevention of dental caries [ 25 ], although the necessity of this intervention may be questioned where flouridated commerical toothpaste is readily available. Educational interventions had mixed effects. A SR that focused on behavioral education, such as demonstrating how to correctly brush teeth, found no evidence for reduction in caries [ 30 ], whereas a SR on oral hygiene and caries education found evidence for decreased plaque and improved hygiene [ 27 ]. More research should be done to identify the content and methods of deliver that make some oral health education interventions more effective than others.

Overall effectiveness of school health services

It is difficult to determine overall effectiveness of school health services from this overview because the included SRs do not sufficiently cover the health areas most relevant for children and adolescents. In 2015, the top five leading causes of death for 5–9 year olds were lower respiratory infections, diarrheal diseases, meningitis, drowning, and road injury [ 47 ]. Among 10–14 year olds, the leading causes of death were lower respiratory infections, drowning, road injury, diarrheal diseases, and meningitis [ 47 ]. Finally, for 15–19 year olds, the leading causes of death were road injury, self-harm, interpersonal violence, diarrheal diseases, and lower respiratory infections [ 47 ]. Leading causes of disability-adjusted life years (DALYs) for 10–19 year olds were iron deficiency anemia, road injury, depressive disorders, lower respiratory infections, and diarrheal diseases [ 47 ]. This overview shows that the current SR literature does address mental health, specifically mood disorders. However, the leading causes of death and disability beyond self-harm and depressive disorders are currently not addressed. Although mortality and morbidity statistics vary by region and country, it is clear that the health areas included in this overview reflect a small subset of the global burden of disease for children and adolescents.

Furthermore, this overview exposes a mismatch between the SR literature on effectiveness of school health services and the actual school health services that are most commonly delivered. Vaccinations have been identified as the most common type of intervention in schools in at least 35 countries or territories [ 9 ], and there is evidence of effectiveness from primary studies regarding feasibility of school-based vaccination programs [ 48 , 49 ]. Yet no SRs on vaccinations fulfilled the inclusion criteria for this overview, suggesting the need for these SRs to be conducted, focusing on whether vaccinations for this age group should be delivered as part of a school health service or not, rather than on whether the vaccination per se is effective. Additionally, at least 94 countries or territories include some form of school health services that are routinely delivered, as opposed to special research interventions [ 9 ]. This overview primarily found evidence for special research interventions, suggesting a need for assessment of routinely-delivered school health services. One of the central questions of this overview was whether the school health services that are regularly delivered across the globe are evidence-based. The mismatch in the SR literature identified by this overview demonstrates that more research must be done before an answer to this question can be determined.

Another important gap that this overview reveals is a lack of research on interventions carried out in LMIC and low-income countries (LIC). Only one of the 20 SRs included in this overview examined studies from a majority of LMIC and LIC [ 22 , 38 ]. This is problematic given that health disparities for children and adolescents are greater in LMIC and LIC than in higher income countries [ 10 ]. Additionally, resources differ by income level and therefore effective interventions in HIC may need to be tailored or changed entirely in order to be feasible in LMIC and LIC. WHO reports densities of less than one physician per 1000 population in 76 countries and less than three nurses or midwives per 1000 population in 87 countries [ 50 ]. Thus, responsibility for interventions may need to be redistributed in countries with limited access to health professionals. This may be solved by coordinating school visits from hospital-based health professionals or by linking schools with local health centers for children and adolescents to access as needed. Given the wide reach of schools [ 8 ] and the fact that school health services already exist in at least 102 countries [ 9 ], research on the effectiveness of school health services in LMIC and LIC must be prioritized in order to fulfill Sustainable Development Goal 3.8 and reach universal health coverage by 2030 [ 51 ].

Although three SRs mentioned the cost of specialized professionals delivering interventions versus teachers or a school nurse [ 26 , 32 , 36 ], cost, let alone cost-effectiveness, was not closely analyzed in any of the included SRs. For useful recommendations to be made regarding school health services, cost-effectiveness must be more closely examined by primary studies and SRs.

Methodological limitations of overviews of systematic reviews

Although overviews offer a comprehensive method for synthesizing evidence, they also come with important methodological limitations. First, an overview is unlikely to include the latest evidence if recent primary studies have not yet been included in SRs. This lag may preclude the ability for an overview to truly reflect current knowledge [ 13 ]. While this overview found significant gaps in the evidence for certain health areas, this does not necessarily mean that relevant high quality primary trials have not been conducted.

Second, the ability of overviews to make valid and accurate conclusions is dependent upon the accuracy, rigor, and inclusiveness of the SRs themselves. 80% (n = 16) of SRs included in this overview were given ratings of low or critically low confidence using the AMSTAR 2 checklist, although this is not unusual given the stringency of the checklist. Nonetheless, it is interesting to note that all four of the SRs given moderate or high levels of confidence were Cochrane reviews. The remaining Cochrane review was given a critically low level of confidence, though this may be because it was published in 2006 and standards for both the methods and reporting of Cochrane reviews have improved in recent years.

Third, the scopes of individual SRs often differ from the scope of the overview, a problem that Ballard and Montgomery call a “scope mismatch” [ 13 ]. In this overview, SRs with at least 50% of included studies fulfilling all criteria were included after extensive discussion between the authors and experts in the field. This implies that a narrower range of SRs would have been eligible if a stricter cut-off had been selected, and vice versa. It is important to take this into account when interpreting results.

Finally, overlap of primary trials between SRs can bias results of an overview [ 15 ]. There is no definitive guidance on how to correct for overlap, as both including or excluding overlapping SRs presents potentially biased results [ 13 , 15 ]. This overview measured overlap using the corrected covered area (CCA) [ 16 ] and did not exclude overlapping studies. However, the degree of overlap across all 20 SRs was graded as being small (CCA = 1), while there was high overlap in SRs on mood disorders (CCA = 11). CCA values for all health areas and calculations are available in Tables C and D in S5 Appendix .

Additional strengths and limitations of this overview

A key limitation of this overview is that only publications self-titled “systematic reviews” were included. This decision was made because of the vast numbers of reviews available and the increased rigor associated with the term “systematic”. In a sensitivity analysis that we conducted comparing “systematic*” with “systematic review” we found that the number of search results increased almost three-fold, but did not reveal any new articles that would eventually have met the subsequent eligibility criteria (search results available on request).

Another limitation is that this overview only included randomized and non-randomized controlled trials, quasi-experimental studies and other controlled study designs where health professionals delivered the intervention. These criteria likely exclude potentially relevant literature. For example, the exclusion of observational studies limits the ability of this overview to assess interventions where controlled studies may be unethical or impractical, such as for an intervention that has been clearly shown to be effective when delivered in a different context and the school health service program wishes to include it. Further, the exclusion of interventions delivered by non-health providers reduces the quantity and breadth of SRs included in this overview. It is likely that some interventions may have the same or perhaps an even better level of effectiveness when delivered by non-health providers, such as a teacher, as compared to when delivered by health providers. Nonetheless, these criteria were necessary to give the overview a reasonable scope. Further, they strengthen the rigor of included studies and improve decision-making ability.

A strength of this overview is that it attempted to answer a question that has not yet been answered regarding the effectiveness of both comprehensive and specific school health services delivered by a health provider. While other pillars of Health Promoting Schools have relevant guidance documents, guidance on school health services is limited and not explicitly evidence-based. Given the wide reach of schools and the fact that school health services already exist in most countries, international guidelines are needed to clarify whether school health services can be effective, and if so, which interventions should and should not be included. This overview makes an important first step toward that guideline.

Conclusions

This overview presents multiple effective interventions that may be offered as a part of school health services delivered by a health provider. However, it is difficult to formulate an overarching answer about the effectiveness of school health services for improving the health of school-age children and adolescents due to the heterogeneity of SRs found and the evident gaps in the SR literature. More than half of included SRs analyzed mental health and oral health interventions, and no SRs were found that assessed other relevant health areas, such as vaccinations, communicable diseases, injuries, etc. Further, no SRs evaluated comprehensive or multi-component school health services. If school health services are to truly improve the health of children and adolescents, they must comprehensively address the most pressing problems of this population. In order for policy makers and leaders in school health to make evidence-based recommendations on which services should be available in schools, who should deliver them, and how should they be delivered, more SRs must be done. These SRs must assess routine, multi-component school health services and the characteristics that make them effective, with special attention to content, quality, intensity, method of delivery, and cost. The gaps in the SR literature identified by this overview will inform the commissioning of new SRs by WHO to feed into evidence-based global recommendations.

Supporting information

S1 appendix. protocol..

https://doi.org/10.1371/journal.pone.0212603.s001

S2 Appendix. Search strategy.

https://doi.org/10.1371/journal.pone.0212603.s002

S3 Appendix. Excluded full text articles.

Table A . Excluded full text articles and reasons for exclusion.

https://doi.org/10.1371/journal.pone.0212603.s003

S4 Appendix. Quality appraisal of primary studies.

Table B . Quality appraisal of primary studies within included systematic reviews.

https://doi.org/10.1371/journal.pone.0212603.s004

S5 Appendix. Corrected covered area.

Table C . Calculation of corrected covered areas (CCAs).

Table D . Classification of primary studies within included systematic reviews for use in corrected covered area calculation.

https://doi.org/10.1371/journal.pone.0212603.s005

S6 Appendix. AMSTAR 2 classifications and results.

Table E . AMSTAR 2 checklist with designations of critical and non-critical.

Table F . Answers to AMSTAR 2 checklist questions 1–16.

https://doi.org/10.1371/journal.pone.0212603.s006

S7 Appendix. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0212603.s007

S8 Appendix. References.

https://doi.org/10.1371/journal.pone.0212603.s008

Acknowledgments

We would like to thank Tomas Allen for his guidance and support in designing the search strategy. We are also grateful for advice from the WHO school health services guideline Steering Group and Guideline Development Group members.

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• Open access
• Published: 14 May 2019

School health and nutrition program implementation, impact, and challenges in schools of Nepal: stakeholders’ perceptions

• Rachana Manandhar Shrestha 1 ,
• Mamata Ghimire 2 ,
• Prakash Shakya 3 ,
• Rakesh Ayer 1 ,
• Rolina Dhital 1 &
• Masamine Jimba 1  

Tropical Medicine and Health volume  47 , Article number:  32 ( 2019 ) Cite this article

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Metrics details

The School Health and Nutrition (SHN) program is a cost-effective intervention for resource-poor countries. SHN program aims to provide timely support and preventive measures to improve the health of school children, which can be associated with their cognitive development, learning, and academic performance. Stakeholders at different tiers can play significant roles in the program implementation and its success. Their perceptions are equally important to provide information on the factors influencing the implementation process and help to identify the gaps in the process. However, the evidence is scarce on the school health and nutrition policy and program implementation in developing countries. No study has yet explored stakeholders’ perceptions on the SHN program implementation process in low-income countries, including Nepal. Therefore, we conducted a qualitative study to explore (1) the SHN program implementation, (2) its impact, and (3) challenges in Nepal.

We conducted a qualitative study through 32 in-depth interviews of the key informants who were actively involved in SHN program implementation in Nepal. The key informants were identified through personal network and snowballing procedure. We adopted a thematic approach for the data analysis.

We categorized interview data into three broad themes: (1) SHN program implementation, (2) its impact, and (3) challenges during implementation. Almost all the key informants appreciated the program for its positive impact on students, schools, and communities. The positive impacts included improved students’ health and school environment and enhanced community awareness. However, the key impediments in implementing the program included a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program.

Conclusions

This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Despite the challenges, all the stakeholders acknowledged that the SHN program had positive impacts on students, schools, and communities. Our findings highlighted that stakeholders from all tiers should coordinate, collaborate, and continue their efforts to effectively implement and expand the program nationwide. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders.

Schools have been a powerful setting to promote health programs [ 1 , 2 ]. The School Health and Nutrition (SHN) program is a cost-effective intervention for resource-poor countries where more schools and teachers are available than health care institutions and workers [ 3 , 4 ]. Many school-aged children in these countries are affected by treatable and preventable illnesses [ 3 , 4 ]. School children’s ill health can be associated with poor cognitive development, learning, and academic performance [ 5 , 6 ]. The SHN program aims to provide timely support and preventive measures to improve the health of school children [ 4 , 7 ].

In 1995, the World Health Organization (WHO) launched the Global School Health Initiative and introduced the concept of Health-Promoting Schools (HPS) [ 8 ], which can be characterized as schools seeking to strengthen their capacity and enable a healthy environment in the schools [ 8 ]. The SHN program is an integral part of HPS [ 9 ], and many countries have adopted the SHN program to promote health through schools [ 10 ].

Health-promotion activities have been successfully implemented through the SHN program in resource-rich countries [ 1 , 5 , 11 ]. However, in resource-limited countries, several operational barriers exist to implement such programs. Major challenges identified include insufficient funds, inadequate physical infrastructures, and lack of trained human resources [ 3 , 12 , 13 , 14 ]. Furthermore, poor coordination and partnerships between stakeholders are also significant hindrances [ 15 ].

In Nepal, the Ministry of Health (MOH) and the Ministry of Education (MOE) jointly endorsed the National SHN Strategy in 2006 [ 16 ]. Since the strategy was endorsed, the Government of Nepal has been conducting the SHN program in different parts of the country with technical and financial support from several aid agencies. The program aims to improve the physical, mental, emotional, and educational status of school children in Nepal [ 15 , 16 ]. However, the coverage of the program activities has not reached many districts in the country [ 15 , 17 ], and most of the support has been limited to the students of government schools [ 15 , 17 ]. Besides, many stakeholders are conducting only selective activities [ 15 ].

To improve the quality of the SHN program, generating evidence is essential. With this aim, in 2013, we conducted an evaluation study of a 4-year-long SHN project jointly conducted by JICA and Nepal Government in Sindhupalchok and Syangja districts [ 18 ]. The project included SHN activities such as general and oral health check-ups, first aid services, deworming, iron supplementation, child club activities, and special health classes, maintaining the SHN register and providing mid-day meals. It also involved school cleaning; improving access to safe drinking water, toilet, and hand-washing facilities; and constructing toilets and waste disposal pits in schools. The teachers in the project schools were trained to conduct SHN activities. The results showed that students in project schools had better access to various school health services, hygiene and sanitation facilities, and more child club activities and special health classes compared to those in comparison schools. Eventually, better access to hygiene and sanitation facilities improved students’ hygiene practices, and their improved hygiene practices were associated with positive health outcomes [ 18 ].

The evidence is scarce on the SHN program implementation process in resource-limited countries [ 9 , 12 , 19 ], and no study has yet explored stakeholders’ perceptions on the SHN program implementation process in low-income countries, including Nepal. Therefore, while evaluating the SHN project, we also aimed to assess the SHN program implementation process in different parts of the country. In the SHN project evaluation study, we only collected data from the school students but did not include other stakeholders, who were actively involved in the SHN program implementation. However, stakeholders at different tiers can play significant roles in the program implementation and its success [ 20 ]. Their perceptions are equally important to provide information on the factors influencing the implementation process and help to identify the gaps in such processes [ 9 , 21 ]. We thus conducted a qualitative study to explore (1) the SHN program implementation, (2) its impact, and (3) challenges in Nepal.

Study design and participants

In this qualitative study, we conducted 32 in-depth interviews with key informants from September to December 2013. We used a stratified purposive sampling technique to choose the study areas [ 22 , 23 ] and included seven out of the then 75 districts. The seven districts were Siraha, Sindhupalchok, Syangja, Kailali, Kathmandu, Lalitpur and Bhaktapur. Kathmandu, Lalitpur, and Bhaktapur districts are in the Kathmandu valley, where MOE, MOH, and different aid agencies were located. Other four districts were selected because several aid agencies were implementing SHN programs in those districts [ 16 , 17 ]. Furthermore, the seven districts represented three physiographic and four out of five the then developmental regions of the country.

Study participants

Table  1 shows the number of key informant interviews conducted from different tiers of stakeholders. We included key informants who were actively involved in the SHN program development and implementation. We recruited the key informants through the personal network of a key person who was also actively involved in the SHN program development and implementation. Using his extensive network of connections and a snowballing procedure, we identified key informants from different organizations who had in-depth knowledge and were actively involved in the program. We conducted office visits and had telephone conversations, and formal and informal talks to track key informants.

The key informants represented four different levels: (1) central level and (2) aid agencies in Kathmandu valley and (3) district level and (4) schools in Siraha, Sindhupalchok, Syangja, and Kailali districts. At the central level, we included two key informants from the Department of Education, MOE, and three from the Child Health Division, MOH. The central-level key informants were involved in the SHN program development, networking, resource mobilization, and monitoring. From the aid agencies, we recruited one key informant from each of seven different international non-governmental organizations (INGOs), and UN and bilateral organizations. The key informants from the aid agencies were involved in supporting the MOE and MOH to implement the program as well as in monitoring and supervising the programs implemented in the schools. At the district level, four key informants from four District Health Office and four District Education Office were recruited from Siraha, Sindhupalchok, Syangja, and Kailali districts. The district level key informants were involved in planning, coordination, resource mobilization, and monitoring of the SHN program in the schools. From the schools also, we recruited four school principals, four teachers, two local non-governmental organizations (NGO) members, one resource person, and one school management committee member from Siraha, Sindhupalchok, Syangja, and Kailali districts. Key informants from the schools implemented and self-monitored the SHN program in the schools.

Data collection and interview guide

The first author and a research assistant conducted all the interviews at the key informants’ workplace, some in English and some in Nepali language. Each interview lasted for an average of 1 h and was tape-recorded and transcribed. Notes were also taken while interviewing. At the end of each interview, the interview notes were reviewed with each key informant to validate what he or she intended to convey. After we felt that data saturation was reached, we stopped the data collection procedure [ 24 ]. We followed the consolidated criteria for reporting qualitative research (COREQ) guidelines to conduct the interviews, and analyze and report the data [ 25 ].

We used a modified interview guide based on the Policy Implementation Assessment Tool for program implementers and other stakeholders, developed by the United States Agency for International Development (USAID) [ 26 ]. The interview guide included open-ended questions and has been used in health policy and program analysis in several low- and middle-income countries [ 27 ]. The guide was translated into Nepali and back translated into English by different individuals to ensure the quality of the translated version.

Data analysis

We conducted a thematic analysis, an inductive approach, using the conceptual framework developed by USAID [ 28 ] to analyze the data from the in-depth interviews. The framework has been designed to show the links between health-related policy development, program implementation, and health outcomes. We employed this framework to identify themes, codes, and sub-codes from the data and analyzed them to understand the data patterns [ 29 ]. We then analyzed the data following the 5-phase cycle proposed by Yin [ 23 ], which includes (1) compiling, (2) disassembling, (3) reassembling, (4) interpreting, and (5) concluding.

In the compiling phase, the research assistants transcribed the interviews. The first author (RMS) then assigned unique code numbers to all the transcripts from the 32 key informants as P1 to P32 (P refers to participant), verified the transcripts with the tape-recorded conversations and written notes.

In the disassembling phase, the first author thoroughly read and reread the transcripts, listened to all the interviews repeatedly, and examined the patterns of interview data. The first author then identified the specific data segments, which were related to study objectives, and gave labels to the data segments to develop preliminary themes, codes, and sub-codes based on the conceptual framework by USAID [ 28 ]. The group of codes and sub-codes, which repeated in a patterned way, were grouped into a theme. The first author then discussed themes, codes, and sub-codes with co-authors. We imported the translated texts into Atlas.ti software, version 5, for data sorting and coding. We distributed the 32 transcripts equally between two groups of co-authors. In each group, two co-authors separately read, sorted, and coded 16 transcripts into previously formulated themes, codes, and sub-codes and then tallied their results to reach consensus. The first author also sorted and coded all 32 transcripts separately. Subsequently, each group tallied their results with the first author’s results to deduce the final themes, codes, and sub-codes.

In the reassembling phase, we reassembled all the data under the same themes, codes, and sub-codes into different groups. In the interpreting phase, we wrote summaries to interpret the data and discussed important quotations. Three co-authors summarized each transcript, selected quotations, and translated them into English. Finally, in the concluding phase, the first author read the summaries and selected quotations to draw conclusions from the data and discussed them with all co-authors.

Ethical considerations

The Research Ethics Committee of the University of Tokyo and the Nepal Health Research Council (NHRC) approved this study. We obtained written informed consent from all the key informants before the interview. We informed them that their participation was voluntary and they could withdraw from the study at any time. We also assured them of confidentiality and anonymity.

We categorized the interview data into three broad themes: (1) SHN program implementation, (2) impact of the SHN program, and (3) challenges during program implementation and suggestions from stakeholders [ 28 ]. Table  2 shows the major themes, codes, and sub-codes deduced from the thematic analysis, showing the linkage between program implementation, impact, and challenges during implementation.

SHN program implementation

Stakeholders involved in shn program implementation.

Majority of the participants from the central, aid agencies, and district level mentioned that there is a structural network from top to down, which included Department of Health Services (MOH), Department of Education (MOE), and different aid agencies at the national level, which were involved in program implementation. At the district level and schools, depending upon the local context and area, the key players involved were District Health Office, District Education Office, schools, Village Development Committee, District Development Committee, local NGOs, health posts, Female Community Health Volunteers (FCHVs), youth clubs, and parents. A few participants from the central level stated about the SHN network, which was also formed with stakeholders from different tiers and has been actively involved in implementing SHN programs as a campaign.

At the central level, the ministry of education, ministry of health, national planning commission and different aid agencies are involved, while at grass root level district health office and education office, schools, school management committee, child clubs, parents, students unions, health posts etc. are the main stakeholders actively involved." (P3, aid agency: WASH specialist)

Now, the SHN network is formed and all the stakeholders involved in it have planned and divided their responsibilities. None of the organizations go directly for the implementation of SHN. We all go through SHN network, which has been a good mechanism where we can coordinate." (P1, aid agency: SHN program coordinator)

Major SHN activities

According to the key informants’ responses from all levels, the major SHN activities could be mainly categorized into four sections, which were based on the four objectives of the SHN strategy [ 16 ]. The activities aimed at achieving these objectives are listed below.

Improve use of SHN services by school students

Majority of key informants responded that they conducted activities such as general and oral health check-ups, first aid services, deworming, iron supplementation, child club activities, maintaining the SHN register, and providing mid-day meals. These activities aimed to improve students’ use of SHN services.

We particularly focused on health examination, oral health check-ups and camps, tooth brushing and hand washing every day, providing mid-day meals, first aid training, providing first aid box to schools, providing training to school teachers and child clubs in the schools." (P1, aid agency: SHN program coordinator)

Improve school environment

Majority of key informants from all levels mentioned that they conducted activities such as school cleaning programs, access to safe drinking water, improving toilet and hand washing facilities, waste disposal pits in school, construction of classrooms, toilets, etc. They mentioned that the above activities helped to improve the school environment.

"Students used to defecate openly in the past, but now they have started using toilets. They collect garbage in the garbage box and after it is filled, they burn it." (P28, school: Health and physical education teacher)

Improve health and nutritional knowledge and behaviors of students

According to the key informants from aid agencies, district level, and schools, they conducted activities such as health education classes, child clubs, and extra-curricular activities to improve students’ health-related knowledge and behaviors. Besides, schoolteachers and child club members were trained to conduct health education sessions on SHN. Awareness programs for parents and community were also conducted.

After the SHN program started, there have been many improvements. For example, this program has improved students’ knowledge of health and hygiene practices and keeping the school environment clean, etc. We have seen many positive changes after this program. (P21, school: Resource person for SHN program)

Improve community support system and policy environment

Some key informants from the central level and aid agencies stated that at the central level, the members of the SHN network and government actively participated in regular meetings to share and discuss the SHN program strategies, activities, and achievements. Some key informants also mentioned that they received support from communities to conduct SHN activities effectively.

At the central level, we are the active members of the SHN network. So we are actively participating in the program. (P3, aid agency: WASH specialist)

Water facility was not available in the schools in Pyuthan district. We had a meeting with parents and teachers and told the parents that we could just give them pipelines. Then, they did all the labor work to set up the pipelines. This is one good example of cooperation between school and community. (P4, aid agency: SHNP senior coordinator)

Impact of the SHN program

Based on the key informants’ responses, we categorized the impact of the SHN program into two main parts a) impact on students, and b) impact on school environment and community.

Impact on students

All the key informants in this study mentioned that the SHN program was successful in improving students’ general knowledge of health and nutrition. Furthermore, the program also brought positive changes in students’ nutritional behaviors, hygiene practices, and life skills. Some participants also appreciated providing tiffin boxes to students, after which many parents started sending tiffin from home in those tiffin boxes.

Students’ awareness on hygiene and sanitary practices has improved. When I was in Dadheldhura, I visited one of the schools there. When I was looking for a toilet, one of the students from grade 3 showed me the toilet and hand washing soap. (P15, district level: SHN program officer, District Education Office)

The tiffin box program would be one of the success stories and good practices. Parents started sending tiffin to their kids in these tiffin boxes. So this is about the behavior change among students as well as their parents. (P5, aid agency: Country program coordinator, School Feeding Program)

Many key informants further stated that the program improved students’ health status by reducing problems such as diarrhea, parasitic infections, anemia, blindness, and hearing loss.

When we conducted the program, we had the baseline and end-line data, which showed a huge reduction in anemia. (P7, aid agency: SHNP former chief advisor)

In the past, there used to be diarrhea epidemics but now there are no such incidents. (P18, district level: District Public Health officer, District Health Office)

Physical screening has helped us to identify vision and hearing impairments. We have prevented kids from becoming blind after vision screening and referring them for further treatments. We have also prevented some kids from suffering permanent hearing loss. (P4, aid agency: SHNP senior coordinator)

Many key informants also mentioned that the program improved the attendance, enrolment, and retention rates in schools. They further suggested that improved health has a positive impact on students’ academic performance.

In the past, students could not understand what they were taught. It’s because their stomach used to be empty. So their focus was more on their empty stomach than on their study. But now all the students bring tiffin. Even if they forget to bring tiffin, their parents bring it to school. So students do not run away from their schools. Their health condition is also getting better. (P29, school: SHN program coordinator, local NGO)

We have qualitative data and reports, which showed students now want to come to school and don’t go back in a break. We have mid-day meal promotion so students come back. For adolescents, we have menstrual hygiene management class, which brings them to school. (P4, aid agency: SHN program senior coordinator)

Impact on school environment and community

Majority of key informants mentioned that the SHN program brought positive changes in the school environment and community. The cooperation between schools and the community also improved. In some areas, communities were mobilized in SHN activities, leading to community awareness.

Children are changing agents. They are promoting health and hygiene not only in their schools but also in their homes and communities. (P3, aid agency: WASH specialist)

In the past, proper coordination and communication did not exist between schools and communities, so the communities used to be dirty with open defecation. Even tooth brushing was neglected. After the child club mobilization, the child club members conducted rallies in the villages to generate awareness among the community people. After receiving the messages from the school children, the communities have been empowered. The open defecation decreased and more toilets were built. Later, an open-defecation-free zone was declared in school catchment areas. Parents have also started brushing their teeth! (P1, aid agency: SHNP program coordinator)

Challenges in program implementation and suggestions from the stakeholders

Lack of coordination between stakeholders.

Majority of key informants responded that MOH, MOE, and their institutions from the central to local levels were responsible to implement the programs and a certain level of coordination existed between them. However, some of the key informants from the central level and aid agencies mentioned that MOH was more active compared to the MOE. Furthermore, the overall coordination between these two sectors was limited, which therefore led to a lack of planning for the sustainability and scaling up of the program.

There are some difficulties with coordination among stakeholders. Horizontal coordination is more difficult than vertical coordination. (P7, aid agency: SHNP former chief advisor)

Most of the organization and ongoing activities come from the health sector. Lower numbers of NGOs or INGOs working in the education sector are involved in SHN program implementation. (P4, aid agency: SHNP senior coordinator)

Though a certain level of coordination exists between the stakeholders, I don’t see that extent of coordination even at the central level, which could generate resources. So I think it is a bit lacking in this part, which can be a challenge for the sustainability of the program (P5, aid agency: SHNP head)

Limited financial, human, and material resources

Almost all key informants in this study responded that the allocated funds for the SHN program were not sufficient to implement all the program components and expand it nationwide. Besides, insufficient human resources and physical infrastructures were other major hurdles. Many key informants from the aid agencies agreed that they have limited resources and could conduct only selected programs in some target districts.

We conducted the SHN project from Japan International Cooperation Agency's (JICA) support. But we are facing difficulties to expand the program because of financial problems. (P9, central level: Director, Child Health Division)

Human and material resources are insufficient from the central to the district level. We have not been able to fulfill the demands. (P8, central level: Chief, Nutrition Section at Child Health Division)

In our school, we do not have teachers with enough knowledge about health issues. Also, we have not been able to use toilets properly and they are smelly because of lack of water facilities. (P26, school: Chairperson, School Management Committee)

By using available funds, we can conduct activities that only meet the indicators proposed by our headquarters. We do not and cannot do all the activities of the SHN program. (P1, aid agency: SHN program coordinator)

Limited training opportunities

All the key informants agreed that training is essential to implement the SHN program effectively. Though the majority of the key informants from the central level and aid agencies stated that they have received different trainings, mixed responses were obtained from the key informants at the district level and schools. Some of them mentioned that they had received the training once, while some were not even aware of such training.

The training was conducted only once and ended and it was not repeated. (P23, school: Health and physical education teacher)

I am the focal person for the SHN program. I have worked in the health training department for 7 years but haven’t received any training related to school health yet and I also don’t know about it. (P16, district level: Chief district officer, District Health Office)

Some key informants from the central and aid agencies responded that the lack of trained human resources and turnover of trained staff members were also impediments during program implementation.

As soon as he/she gets some training, he/she will be transferred somewhere else due to either personal interest or organizational changes. (P12, central level: Deputy Director of Education Division)

Sustainability of the program

Almost half of the key informants from different levels were positive regarding the sustainability of the program, while others were doubtful due to lack of resources.

It is not sustainable. We don’t have enough resources. We have conducted it in two districts but could not expand it to other districts. So if resources are available, we can make it sustainable. (P9, central level: Director, Child Health Division)

Suggestions from the stakeholders

Despite several challenges identified by the stakeholders during the implementation of SHN programs, all of them acknowledged that efforts should be made to make the program sustainable, because of its positive impact on students, schools, and communities. Some of the key informants from the central level and aid agency suggested that MOE should also get actively involved in the program implementation. Besides, a few respondents at the central level mentioned that the program could be sustainable if it is integrated into the government system.

The education sector should be more involved, as the Ministry of Education is also on board. (P4, aid agency: SHNP senior coordinator)

The program will be sustainable if it is integrated into the government system. Aid agencies come and once they are gone, the District Education Office and communities cannot make the program sustainable by themselves. (P4, aid agency: SHNP senior coordinator)

Some of the key informants also provided suggestions on resource generations. One of the key informants from the aid agency mentioned that the stakeholders should coordinate well to generate resources. Some key informants from the schools even mentioned that they tried to generate funds from local sources.

In my opinion, the coordination between the stakeholders should also act on pulling up the resources for implementing the program. (P5, aid agency: SHNP head)

Child clubs in schools organize Deusi-Bhailo program (cultural program) during Tihar festival and collect fund. The child clubs also charge membership fees to generate fund, which they use for school health and nutrition program activities (P23, school: Resource person for SHN program)

Regarding training on SHN program implementation, stakeholders at districts and schools who had received training on SHN program implementation once, suggested that such training should be more frequent and longer and also mentioned that it should be expanded to other parts of the country. They also suggested that all the teachers in the school should be trained.

The training was conducted only once and such training should be conducted repeatedly. (P23, school: Health and physical education teacher)

We need basic training for all teachers. I don’t think training only one focal teacher is sufficient. (P27, school: School principal)

In this study, almost all the key informants appreciated the SHN program implementation in schools and the positive impact it has on students, schools, and communities. The positive impact included improved students’ health and education outcomes, improved school environment, and enhanced community awareness. However, key informants also identified key impediments in implementing the program: there was a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program.

SHN program implementation and impact

According to many key informants in this study, a broad array of stakeholders was involved from the central level to schools in implementing the SHN programs based on the SHN strategy in the country. MOH and MOE were the lead institutions for implementing the program. Aid agencies were also playing significant roles in implementing programs in different parts of the country. At district level and schools, DOH, DOE, schools, health posts, local NGOs, FCHVs, youth clubs, and parents were actively involved. Understanding the roles of different stakeholders is essential to analyze the implementation process of a program [ 30 ].

The majority of key informants mentioned that after the implementation of SHN program in the schools, students had better access to different SHN services, better nutrition, safe drinking water, and hygiene and sanitation facilities. They also acknowledged that the program significantly improved students’ knowledge, awareness, and practices regarding health and hygiene issues. The improved practices included hand washing, using soap while hand washing, and wearing clean school uniforms. Child clubs and extra-curricular activities could have played a significant role in improving students’ health and nutritional knowledge and practices. Similar child club activities are known to help students gain knowledge and learn life skills for their personal development in Nepal [ 31 ]. Furthermore, better access to hygiene and sanitation facilities in schools due to the SHN program could be associated with students’ better hygiene practices. Our previous quantitative study also showed that child clubs and special health classes were positively associated with students’ higher health knowledge scores and identified a positive association between better health and sanitation facilities and students’ improved hygiene practices [ 18 ]. The SHN program has also shown short- and long-term positive impact on students’ attitude, practices, health, and academic outcomes worldwide [ 10 , 32 , 33 ].

Many key informants also mentioned that the program had a positive impact on students’ health status, such as reduced diarrheal diseases, worm infestations, and anemia. Students’ better access to SHN services such as deworming, and iron and vitamin A supplementation might have played a significant role in the improved health outcomes. According to a few key informants, physical screening could have also prevented blindness and hearing loss in some students. Our previous study also showed a positive association between the SHN program and students’ better health outcomes [ 18 ]. Moreover, many key informants reported that students’ school enrolment, retention, and attendance rates increased after implementation of the SHN program. This finding may imply that healthy students attend school more regularly and stay longer in schools, which can have a positive impact on their academic performance [ 34 , 35 ].

Furthermore, this study showed that after implementing the SHN program in schools, more parents sent their kids to school with tiffin and wearing a clean uniform. School children might have played a role as changing agents and generated awareness about nutrition, personal hygiene, and cleanliness at home and in their communities. These findings indicate that SHN program has helped to sensitize parents and community members about child health-related issues and promoting healthy behaviors; therefore, they also benefited from the program. Moreover, parents and community members can also play a significant role in encouraging children to practice healthy behaviors and keep their school environment clean, safe, and healthy [ 36 ]. Similar findings were also reported in the end-line survey of the SHN project conducted in Sindhupalchok and Syangja districts [ 37 ].

Despite the positive impact of the SHN program on students, parents, and communities, this study identified several barriers and challenges to implement the program. Some of the key informants from the central and aid agency mentioned that horizontal coordination was lacking between the MOH and MOE. According to the institutional framework of the SHN strategy, the two ministries were the lead institutions to implement the program in Nepal, and aid agencies were the key implementing partners [ 16 ]. However, some key informants mentioned that the MOH and its institutions at the central to local level were more active compared to the MOE. This suggests that only one sector was actively involved in the implementation of the SHN program in Nepal. A similar situation was reported in the Lao People’s Democratic Republic (PDR), where the education sector had a leading role in implementing the National School Health Policy in the country [ 12 ]. A few studies have also reported a lack of coordination between the two ministries while implementing school health programs [ 9 , 12 , 13 ]. This gap could have led to the lack of intensive planning at national level which might be one of the reasons why the program could not be scaled up in other parts of the country as expected [ 12 ]. However, a few key informants in this study mentioned that regular meetings were held among the SHN network members at the central level to discuss program activities, achievements, and problems. These meetings might be helpful to improve program implementation [ 38 ].

Furthermore, most of the key informants identified insufficient funds and lack of material resources as the major hurdles to implement a comprehensive and nationwide SHN program. Many schools did not have sufficient physical infrastructures or facilities to implement the program efficiently. In resource-limited countries, a lack of resources has been a crucial operational barrier to conduct the program [ 3 , 12 , 13 ]. Our findings suggest that the SHN program in Nepal was not an exception. Aid agencies were one of the main sources of funding for the program in the country. However, the key informants from aid agencies also mentioned that they only had funds to implement the program in their target districts. They suggested that good coordination between the stakeholders might help in generating resources. Because of insufficient money, some schools even raised funds from parents and community members. This finding is encouraging and suggests that mobilizing community members to generate resources at the local level and reduce over-dependence on external aid agencies [ 14 ] may be effective to sustain SHN activities in Nepalese schools.

This study further showed that the lack of trained human resources to implement SHN was another key impediment. Although most of the key informants from the central level and aid agencies received and provided training to implement the SHN program, only some key informants from the district level and schools received the training. A few of them were not even aware of such training programs on SHN activities. Besides, only one focal teacher in each school was trained to conduct SHN activities and the students did not have access to the trained health professionals at schools. These findings indicate the dearth of trained human resources to conduct the program effectively. However, capacity building of human resources from the central level to schools is known to be a requisite to improve and sustain the program [ 12 , 39 ]. A review study also reported that school health promoters required more training to overcome problems while implementing the health-promoting school programs [ 38 ]. During the 4-year SHN project in Sindhupalchok and Syangja districts, teachers and staff from the District Education Office and District Health Office were trained once to conduct SHN program activities [ 37 ]. In the present study, many key informants responded that after the project ended, such training was not conducted anymore. Moreover, a few of them identified the turnover of trained staff as a challenge, which is similar to the findings of a study from the Lao PDR [ 12 ]. Therefore, our findings warrant the need for regular and refresher training, and the establishment of training centers to generate trained manpower to implement the SHN program effectively and sustainably.

This study showed that the sustainability of the SHN program was a challenge because of insufficient material and human resources, and lack of strong leadership. A few of the key informants suggested integrating the program into the government system to make it sustainable. Program sustainability depends on the government’s strong leadership, long-term funds, and trained human resources [ 40 , 41 ]. Despite the challenges, all the key informants in this study unanimously agreed to make efforts to increase the program sustainability, given its positive impact on students, schools, and communities. Some key informants even mentioned that in some schools, communities provided their support and took the initiative to conduct SHN activities, which suggests that communities can play a significant role in making the program sustainable.

Limitations

The results of this study should be interpreted considering three limitations. First, we collected data from school-level key informants only in the districts where the SHN program was conducted. Therefore, key informants’ responses in this study may not represent stakeholders’ perceptions throughout the country. However, we interviewed key informants from different tiers including the central and district levels, schools, and aid agencies. Second, we did not include parents as key informants in this study though they are important stakeholders in SHN program implementation and their perceptions might have given additional insights. However, they were the least active stakeholders in implementing the program, and thus we have tried to understand their perceptions from school principals and focal teachers, who were communicating with parents on a regular basis. Third, the key informants might have expressed the views that they thought we (investigators) wanted to hear, leading to social desirability bias. However, we conducted interviews in the closed room in their office settings. We also assured them about the confidentiality of the information they provided and the anonymity of their identity. Despite these limitations, this is the first study in Nepal to explore the perceptions of stakeholders from all tiers regarding the SHN program implementation, impact, and challenges.

This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Stakeholders from all tiers identified several operational barriers to implementing and expanding the program throughout the country. The four major challenges identified by the stakeholders were lack of coordination between stakeholders, lack of resources, lack of training opportunities, and low sustainability of the program. Despite these challenges, all the stakeholders acknowledged that the SHN program had positive effects on students, schools, and communities and provided some suggestions to improve the implementation of SHN program in the country.

Our study further highlighted that stakeholders from all tiers should coordinate and collaborate adequately to continue their efforts to implement and expand the program nationwide. Furthermore, MOH and MOE should jointly provide strong leadership and recognize their responsibilities to improve students’ health and academic outcomes. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders. Besides, the government should implement programs to encourage schools to generate resources at the local level and discourage over-dependency on external sources to make the SHN program sustainable.

Abbreviations

Consolidated criteria for reporting qualitative research

Female Community Health Volunteers

Health-Promoting Schools

International non-governmental organizations

Ministry of Education

Ministry of Health

Non-governmental organizations

School Health and Nutrition

United States Agency for International Development

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Acknowledgements

The authors would like to express their sincere gratitude to all the key informants who participated in this study. They also gratefully acknowledge the logistic support provided by all the research assistants, particularly Mr. Arun Khanal and Ms. Moe Miyaguchi during the fieldwork. The authors would also like to thank Editage, Japan, for English language review.

This study was supported by a Grant from the National Center for Global Health and Medicine ( http://www.ncgm.go.jp/ ) (grant number: 27S1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Rachana Manandhar Shrestha, Rakesh Ayer, Rolina Dhital & Masamine Jimba

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Graduate School of International Cooperation Studies, Kyorin University, 5-4-1, Shimorenjaku, Mitaka-shi, Tokyo, 181-8612, Japan

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RMS conceived the research questions, designed the study, conducted the fieldwork, analyzed the data, and prepared the manuscript draft. MG, PS, RA, and RD were involved in data analysis and manuscript revision. MJ was involved in research proposal designing, manuscript revision, and supervision of the whole process. All authors read the manuscript and approved for submission.

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Shrestha, R.M., Ghimire, M., Shakya, P. et al. School health and nutrition program implementation, impact, and challenges in schools of Nepal: stakeholders’ perceptions. Trop Med Health 47 , 32 (2019). https://doi.org/10.1186/s41182-019-0159-4

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Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

• M. Pearson 1 ,
• R. Chilton 1 ,
• K. Wyatt 1 ,
• C. Abraham 1 ,
• T. Ford 1 ,
• HB Woods 2 &
• R. Anderson 1  

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Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children’s and young people’s health. However, understanding of how such programmes can be implemented in schools is more limited.

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

In consultation with the review advisory group, we developed four programme theories ( preparing for implementation , initial implementation , embedding into routine practice , adaptation and evolution ); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity—the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

Conclusions

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Peer Review reports

Schools have long been viewed as a good setting in which to encourage healthy lifestyles and choices amongst children. The practice of health promotion in schools has been reinforced by the World Health Organization’s (WHO) Ottawa Charter for Health Promotion [ 1 ], the lifetime health and well-being benefits for children and communities that are expected to follow [ 2 ], and latterly by research evidence of synergy between health and education [ 3 ]. Schools in many countries aspire to more comprehensive, integrated approaches to health promotion which address both individuals’ attitudes and behaviours and the school environment [ 4 , 5 ]. The WHO concept of health-promoting schools [ 2 , 6 , 7 ], known also as a ‘settings’ approach [ 8 ] and in North America as coordinated school health programmes, provides a framework for those approaches which incorporate a formal health curriculum; promotion of a healthy school environment and ethos that can benefit pupils, teachers, and non-teaching staff alike; and engagement with families and communities [ 9 ].

Recent reviews have identified evidence about the contribution that comprehensive, integrated approaches to health promotion in schools can make to improving children’s and young people’s health in a number of areas [ 9 , 10 ]. Understanding of how these effects are attained is increasing [ 11 ]. However, understanding of how the constituents of such programmes can be best implemented in schools remains a neglected area [ 12 ].

The reality of implementing health promotion programmes in schools involves the active engagement of a range of actors [ 13 , 14 ] and the adaptation of programmes to local contexts [ 15 , 16 ] within a wider educational and public health system. They can thus be considered as complex interventions (multi-component, context-sensitive, and highly dependent on the behaviours of participants and providers) within a complex system [ 17 ].

Our aim was to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools (see Table  1 for definitions) taking full account of these complexities. Our research questions were as follows:

What are the main factors or mechanisms that are thought to explain the success or failure of the implementation of health promotion programmes in schools?

Is there an association between these factors and mechanisms and the successful implementation of health promotion programmes in schools?

For what public health problems and in what circumstances do schools provide a feasible and sustainable setting for health promotion in the United Kingdom?

We chose to conduct a realist review in order to attain a contextualised understanding of how and why complex interventions achieve particular effects—in realist terminology (see Table  1 ), how mechanisms lead to outcomes in particular contexts [ 18 , 19 ]. The realist approach involves testing ‘programme theories’—often expressed as a model linking outcomes to programme activities and the underlying theoretical assumptions [ 20 ]. This approach has commonalities with other approaches such as Intervention Mapping [ 14 ] and Medical Research Council guidance on process evaluation of complex interventions [ 21 ], but differs by being explicitly situated in a realist philosophy of science [ 22 , 23 ]. A realist philosophy of science posits that the identification and testing of contextualised, generative mechanisms provide the greatest explanatory potential for phenomena and the strongest basis for inferring how mechanisms will operate in other contexts [ 23 ]. It differs from an ‘idealist’ philosophy that endeavours to establish causation by ruling out alternative atheoretical patterns.

Contained within programme theories, even if not explicitly stated, are ideas about how a problem can best be addressed and how factors that may undermine the actions of the programme can themselves be addressed [ 24 ]. Realist review methods have been specifically advocated for evaluating evidence about complex interventions and their implementation [ 19 , 25 ]. For this topic, three factors led us to choose realist review over a mediator and moderator analysis. First, the measures (or ‘markers’) of implementation are not well-developed or standardised. Second, we envisaged that the diversity of trial methodology and complexity of the relationships between phenomena would be likely to preclude use of meta-regression of multivariate studies. Third, the diversity of qualitative and quantitative research evidence required a coherent approach for synthesis.

The review was conducted in two phases. First, ideas about what enables or inhibits the implementation of health promotion programmes in schools (programme theories) were identified from a range of published and other sources. Second, these programme theories were tested (challenged, endorsed, and/or refined) using evidence from evaluations of United Kingdom (UK) school health promotion programmes. We endeavoured to identify mechanisms (how a programme’s resources or opportunities interact with the reasoning of individuals and lead to changes in behaviour) and contexts (the wider configuration of factors, not necessarily connected to a programme, that may enable or constrain the operation of specific mechanisms) so that context-mechanism-outcome configurations could be specified. The identified evidence meant that this was possible to a much greater extent in relation to earlier (preparation and initial implementation) rather than later (embedding and evolution) stages of implementation. Our focus on implementation therefore includes intervention delivery characteristics that are often evaluated in conventional effectiveness studies [ 26 ] but extends this focus to include levels of complexity about those delivering a programme and the system in which they practise.

The full protocol for the review has previously been published [ 27 ]. The review is reported in accordance with the RAMESES publication standards [ 28 ].

Search strategy

Our approach to searching was iterative, consisting of sensitising, wide-ranging, and supplementary searches. This enabled us to map and explore a wide range of conceptual sources relating to the implementation of health programmes (both in schools and other settings), whilst also locating empirical studies conducted in the UK for programme theory testing.

Screening (theory-development stage)

The first stage of the review was designed to both identify and develop programme theories and to ‘map the terrain’ of the implementation of health promotion programmes in schools in Organisation for Economic Co-operation and Development (OECD) countries. Sources that provided rich descriptions of the delivery of school-based health promotion for children aged 5–16 years in any OECD country were included. These included editorials, opinion pieces, commentaries, comparative effectiveness studies, process evaluations, qualitative research, and systematic reviews.

Titles and abstracts were read by the reviewers (MP, RC) to identify key ‘implementation’ terms and synonyms that could inform the development with the information specialist (HW) of the ‘sensitising’ search strategy. Key documents relating to the implementation of health programmes in schools were also identified and used to search for other documents which had cited them. We deliberately used a wide definition of ‘key’—for example, sources could be considered ‘key’ because they were a candid reflection on the implementation of a health promotion programme or because they were strongly conceptualised (i.e. a strongly theoretically informed inquiry). This stage was also used to ‘sensitise’ us as researchers to the emerging field of implementation science (as it related to health promotion in schools) and to potential programme theories.

However, we did not intend for the sensitising stage to be exhaustive—the aim was to locate a reasonable range of terms and sources that could inform further searches and deepen our understanding of the field (see Additional file 1 for record of (and reasons for) the sources obtained).

To help focus our identification and development of programme theories, we kept in mind examples of theories that struck a balance between being broad enough to identify a potentially significant relationship and specific enough to be testable (i.e. middle-range theories, the most useful theories on which we would focus in our development of bespoke programme theories). These middle-range theories can be thought of as lying between localised and non-theoretical individual examples or instances and broad, generic theories, both of which would be harder to test using information about particular programmes.

Screening (theory-testing stage)

For inclusion in the second stage of the review, studies had to be linked to an empirical evaluation of a primary- or secondary-school-based health promotion programme in the UK (i.e. schools for children aged 5–16 years). For example, a process evaluation that documented implementation processes alongside a trial was considered to be ‘linked’. We included evaluations that used a range of comparative study designs—RCTs, controlled before and after studies, and before and after studies. Detailed inclusion criteria are described in the protocol [ 27 ].

Screening was conducted by two reviewers (MP, RC) using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education) to manage references and record coding decisions.

We ‘mapped’ sources for both theory-development and theory-testing stages in two main ways. We first used the abstract to assess the likely clarity, richness, and extent of conceptualisation of programme theories that a source could potentially provide. This assessment used criteria proposed by Ritzer [ 29 ] and Roen et al. [ 30 ] (Table  2 ). We then categorised sources by ‘type’—policy document, editorial, opinion piece or letter, commentary, reflection on practice, comparative effectiveness study, evaluation and/or process evaluation, qualitative research, survey, systematic review, narrative review, or conceptual review. This enabled us to use a sampling strategy which focused on those sources that would potentially contribute the most to the development of a conceptual framework (i.e. those that were ‘conceptually rich’). It also enabled us to purposively sample ‘less conceptually rich’ sources such as policy documents or editorials that could nevertheless contain important contributions for the development of a conceptual framework. This strategy was informed by the idea of ‘theoretical saturation’, where data collections stops at the point at which collection of further data is considered unlikely to yield further insights [ 31 ]. The flow of studies through the review is shown in Fig.  1 .

Flowchart of sources through the review

Development of programme theories

We recognised from the outset that building a conceptual framework for the implementation of health promotion programmes in schools would be a process that initially focused on discussion and debate within the research team. Both reviewers (MP and RC) read, annotated, and took notes from all of the sources categorised as conceptually rich ( n  = 19) with a view to producing a coherent framework that encompassed all of the implementation aspects identified in the sources. We pursued citations from these sources where we judged that they held potential to contribute substantively to the conceptual framework and, as a result, included two further sources. One was directly related to health promotion in schools [ 32 ] whilst one was not specific to health promotion but related to change at the level of the school [ 33 ]. One further source categorised as ‘thick’ was included [ 15 ] as it was closely linked with another conceptually rich source [ 34 ]. A total of 22 sources informed the development of the conceptual framework and theory-development review phase (Additional file 2 ).

Amongst these, a narrative review by Samdal and Rowling [ 5 ] presented a list of eight ‘rationales for implementation components’ that were presented in a form similar to programme theories. We took the decision to use these theories as our starting point from which to explore how the programme theories in the other 21 conceptually rich sources could expand or refine these theories. This enabled us to develop a ‘long list’ of 12 programme theories (Additional file 3 ) that encompassed all of the concepts around implementation identified in the 22 conceptually rich sources (including the Samdal and Rowling narrative review [ 5 ]) and to identify the unique contributions of each source. These programme theories were developed and prioritised further on the basis of discussions in our first review advisory group meeting with educational and health professionals and health researchers (see Additional file 4 for further details).

The final expression of four programme theories encompassed the processes of preparing for, introducing, embedding, and adapting health promotion programmes in schools. These were discussed and agreed via email correspondence with the advisory group’s members. The three stages of programme theory development, showing the areas in which different sources contributed, are documented in Additional file 5 .

Testing of programme theories

To help guide our efforts in the extraction and synthesis of relevant evidence from included studies in the second (theory-testing) stage of the review, we summarised the programme theories in a conceptual framework (Fig.  2 ). Phase 2 of the review included evaluations of health promotion programmes delivered in UK primary or secondary schools that reported findings that enabled aspects of the four programme theories to be tested. Table  3 lists the details of the 41 included papers, reporting evaluations of 20 different health promotion programmes in schools—11 of which were delivered in primary schools and 9 in secondary schools. A brief summary of each programme is provided in the table, with full details reported in Additional file 6 .

Conceptual framework for designing and implementing health promotion programmes in schools

Critical appraisal

All included studies were critically appraised using the Wallace et al. [ 35 ] tool for assessing quantitative, qualitative, and mixed-methods studies. This enabled the strengths and weaknesses of different aspects of each study to be identified, rather than a summary verdict on the quality of the whole study. A summary of the key points of the critical appraisal was included in each data extraction table and collated in a summary critical appraisal table (see Additional file 7 ).

Data extraction

Information on study type, the programme being evaluated, the content and delivery of the programme, and research methods (sample, participants, data collection and analysis) and evidence to enable testing of each of the four programme theories were extracted to data extraction tables (Additional file 8 ). To facilitate synthesis, where evaluation of a health promotion programme was reported across multiple publications, all data was extracted to a single table.

As evidence to test the programme theories was rarely reported in a consistent format or section within papers, we used contents pages, the executive summary, sub-headings, and/or the conclusions (as appropriate to the publication type) in order to ‘gain a foothold’ and start the process of reading and data extraction. This was an iterative process which involved our critical consideration of the extent to which studies’ findings enabled the programme theories to be tested. Our decision-making was guided by looking for ‘markers of implementation’ (for example, stakeholders’ experiences, perceptions, and competencies—see Additional file 9 ), although we did not limit extracted data to only these ‘markers’ if we judged other evidence to be relevant. For example, relevant evidence could be indirect, such as the effect of homophobic attitudes (on the part of both teachers and pupils) on levels of engagement in sex and relationship education (SRE).

The volume of reported information in some studies and our desire to not lose the potential contribution of authors’ analyses to the synthesis meant that we judged when it was necessary to either summarise data or extract authors’ analyses. Here we used the distinction made in meta-ethnography between first- and second-order interpretations [ 36 ]. In recording data, we used double quotes where study participants’ views, experiences, or understandings were reported in their own words (first-order interpretation) and single quotes where study authors’ analyses were extracted (second-order interpretations). As our aim was to identify and extract key pieces of information, we recorded additional contextual information or critical appraisal findings immediately adjacent to the relevant extracted data. This guarded against our synthesis being conducted without knowledge of these factors, which might relate to a particular piece of evidence but not the study as a whole. To attain consistency, each critical appraisal and data extraction was checked by the lead reviewer (MP), with feedback or revisions provided as appropriate.

Consistent with a realist approach to the explanation of complex phenomena, where relationships between phenomena may be multi-factorial, inter-dependent, and emergent, we treated the ‘ways of synthesising’ as principles to critically apply rather than strict instructions to use on each piece of evidence. The iterative and explanatory nature of synthesis in a realist review meant that the processes of juxtaposition, reconciliation, consolidation, situation, and adjudication of different sources and evidence [ 18 ] (see Table  1 ) were used in combination rather than separately. Whilst we had conducted critical appraisal before the synthesis (rather than concurrently, as advocated by Pawson [ 37 , 38 ], in adjudicating between different sources, we were careful to use the findings of the critical appraisal in relation to the relevant aspects of or insights from a study rather than judging the validity of each study as a whole. If our initial critical appraisal was unable to support a judgement about a particular piece of evidence, we returned to the original source so that a bespoke appraisal incorporating rigour and relevance could be made. We believe that this is a more transparent process for incorporating rigour and relevance in the conduct of a realist synthesis than solely appraising studies during synthesis.

Throughout the synthesis, we bore in mind the implications of emerging explanations for testing each of the programme theories. Details of the practical stages of the synthesis can be found in Additional file 10 .

We present our findings as a summary of contextualised mechanisms relating to each of the issues encountered in each programme theory, noting the depth, breadth, and overall rigour of the underlying evidence. The summaries are intended to facilitate decision-makers’ and practitioners’ sensemaking of local contexts, thereby facilitating self-organisation at the local level [ 39 ].

To enhance the readability of the summaries within a limited space, citations to the evidence underpinning each programme theory are contained in Table  4 (rather than in the text) together with a summary of context-mechanism-outcome configurations. Additional file 11 contains a longer version of the findings (see Table  4 for page numbers relating to each context-mechanism-outcome configuration), with examples and greater detail about the rigour of individual pieces of evidence used in the synthesis.

Programme theory 1: preparing for implementation

Pre-delivery consultation.

Whilst the rigour of the underlying evidence is highly variable, both the type of health promotion programme and the recent school history of delivering programmes on the topic are likely to impact on the extent and depth of pre-delivery consultation needed. A more ‘mature’ and uncontentious area of health promotion such as physical activity, where there is a history of delivering similar programmes and existing staff and organisational networks provide a foundation to support programme delivery, is likely to require substantive but brief ‘pre-delivery’ consultation with school staff and parents. Where aspects of health promotion are less well-established, such as social and emotional issues in SRE, and where the topic may be a highly charged personal issue for teachers (for example, in terms of morality and sexual identity), more extensive ‘pre-delivery’ consultation with school staff and parents is likely to be necessary. Areas of health promotion such as healthy eating and smoking prevention, whilst relatively uncontentious, may still require significant pre-delivery consultation, especially where a programme contains novel components of delivery or content with which school staff are unfamiliar.

Pupil engagement

Making a health promotion programme appealing to pupils is not necessarily straightforward. Programmes need to be developmentally appropriate and address issues perceived as relevant by pupils, whilst at the same time stretching pupils’ understanding of health issues that may lie well outside of their experience or understanding. ‘Sweeteners’ can play an important role—pupils are strategic thinkers themselves and may well respond to the ‘multiple pay-offs’ that a programme can offer such as the development of transferable educational or life skills. None of these more complex considerations should pressurise programme designers and school staff into overlooking the potential of a simple ‘hook’, such as the novelty of an external provider, for engaging pupils’ attention.

Reciprocity

Preparing for the delivery of a health promotion programme in a school revolves around reciprocity. On the whole, teachers will devote their time and energy if they believe that they will get the practical and educational support to enable them to play their role. Even if this reciprocity is more symbolic than practical at the initial stages, it can start a process of engagement that fosters co-operation towards achieving a common goal, such as improved health outcomes for pupils through delivery of a health promotion programme.

Reciprocity is also important for pupils. Long-term health gains are mostly an abstract concept for pupils of both primary and secondary school age, so they need to perceive other, more short-term (and non-health) gains from participating in a health promotion programme. Amongst other things, this can be related simply to enjoyment (having some fun), identity development (e.g. status amongst peers), or mid-term goals (e.g. developing transferable skills).

Both teachers and secondary-school-age pupils try to ensure that actions contribute to more than one beneficial outcome. This does not override the contribution of intrinsic motivation, such as teachers’ desire to play a pastoral role in child development or pupils’ appreciation of knowledge about a healthy lifestyle. However, it does highlight that the delivery of a health promotion programme in a school has to take place within current frameworks that demand outcomes on many levels. Teachers will want to balance pupils’ educational goals and psycho-social development with the demands of the local and school political environment, their personal work/life balance, and career development. Pupils will want to achieve their educational goals and develop psycho-socially (albeit this may simply be perceived as ‘growing up’). The extent to which the preparation for delivery of a programme considers how these diverse goals can be accomplished is central to successful implementation.

Negotiation (about SRE programme delivery)

There is evidence from a well-conducted process evaluation of a SRE programme (the SHARE programme—Sexual Health and Relationships: Safe, Happy and Responsible) that negotiation about, and adaptation of, health promotion programmes in schools takes place in a wider context than ‘health’. At the school level, decisions about programme content and delivery are political in the sense that they aim to balance the views and demands of a broad range of stakeholders. The extent to which this applies in areas of health promotion other than SRE is unclear.

Concordance of the programme with current practice and interests

There is weaker, observational evidence from a range of health promotion programmes that concordance between a programme and current school activities and priorities works in a number of different ways:

Meeting an unmet need in a school in a way that is consistent with other school activities (i.e. ‘meshing’)

‘Working with’ and therefore contributing to the development of a particular school ethos (i.e. ‘complementing’)

Co-ordinating other school activities to fit with programme components (i.e. ‘driving’)

Sometimes, even where there appears to be a lack of concordance between a programme and some school activities, this can act as a stimulus for change and mutual accommodation. However, this may require early recognition and careful negotiation.

Programme theory 2: introducing a programme within a school

Integrating a programme into the life of a school.

Active support by senior figures within a school is necessary but has to extend deeper than written policies—the ways in which policies will be put into action ‘on the ground’ need to be specific and clear. This is because the organisation and delivery of health promotion programmes can be experienced by teachers as an additional responsibility, and one which they are unlikely to want to ‘go the extra mile for’ if doing so is perceived as risky for their professional life, personal well-being, or work-life balance. The pathway of programme introduction and delivery needs to be both paved (practical assistance—specific training, resources, and co-ordination with other aspects of school life) and sheltered (from local or national outside parties who disagree with a programme’s focus or approach).

The importance of this ‘on the ground’ support broadly follows a continuum, with support being less pivotal at the primary school level where a teacher’s class usually consists of the same group of pupils and less contentious health promotion topics are addressed. At the secondary school level, where pupils’ subject options can lead to more change in class composition, there may be pronounced differences in levels of maturity, and as more contentious health promotion topics are addressed, this support becomes more important. The need for and specific type of support and training will also critically depend on whether the people delivering the programme are teachers or other professionals working within a school. For example, teachers may need skills and confidence in specific behaviour change techniques that are part of the programme, whereas outside professionals delivering the programme may need skills and confidence in classroom management.

Whether programmes are delivered by teachers, external professionals, peer educators, or a mixture of these, in both primary and secondary schools, it was consistently reported that a named co-ordinator was important for initiating and sustaining programme delivery. The profession or status of this person, and whether or not he/she was a school employee, was far less important than his/her willingness to co-ordinate, his/her skills and capacity to do so, and his/her ability to exert influence within the school.

Engaging those who deliver and participate in health promotion programmes

Across both primary and secondary school levels and a range of health promotion topics, the motivation of those delivering programmes to engage in training depended on whether or not the training addressed knowledge or skill deficits that were relevant from their point of view. This links with reciprocity (see programme theory 1 summary)—both teachers and pupils are more likely to engage when they can see the likely personal, social, and/or developmental gains from participating. Engagement can be problematic where there is discordance between health promotion topics and personal values, although this is only reported in relation to SRE.

The engagement of pupils as participants broadly follows a continuum in line with psycho-social development. At the primary school age, the key issue is whether or not a programme is fun. As pupils progress through the secondary school years and health promotion addresses more contentious issues such as sexual relationships and substance use, fun remains necessary but is not sufficient. Addressing a perceived skill or knowledge deficit and the quality of the relationship between participants and those delivering the programme assume a greater importance. Participants’ confidence in the maintenance of confidentiality can be highly important for engagement in topics such as SRE and substance use.

In both primary and secondary schools and for a range of health promotion topics and programme types, engagement was facilitated by programmes being sufficiently flexible to allow tailoring to different levels of pupils’ physical, psychological, and social development and different levels of skill and experience (both of pupils and those who are delivering a programme).

Programme theory 3: embedding a programme into routine practice

The research timeframes of included studies were mostly too short (2 years or less) to produce evidence about the embedding of health promotion programmes. There is limited evidence in the short term about the impact of co-ordination of programmes with other school activities, but this does not add substantively to that identified in the programme theory 2 summary. Other evidence about embedding is limited to the views of teachers and managers about aspects they think would help, such as senior support and networking. However, the fact that teachers and managers had to venture ideas about how to embed programmes strongly suggests that considerations of sustainability were simply not part of any of the design of programmes.

Programme theory 4: fidelity of implementation and programme adaptation

There was substantial variation across all programmes in how they were delivered in different schools, but in the included studies, it was not possible to distinguish ‘warranted variation’ (for example, based on informed professional judgement) from ‘unwarranted variation’ driven by other factors. The usefulness and acceptability of programmes where core and customisable elements were specified was not evaluated, although there was considerable ambivalence expressed by teachers about the usefulness of more prescriptive programmes. An evaluation of a SRE programme suggests that fidelity of implementation is enabled when teachers work within a collegial atmosphere where issues about programme delivery can be openly discussed with colleagues and support obtained from senior staff in the school and the programme’s developers.

This is the first review of the implementation of health promotion programmes in schools to have been conducted using a recognised review method. The use of realist review was novel in this field, and through its application, we have been able to improve understanding of transferable mechanisms rather than simply identifying de-contextualised implementation processes. Our review has consolidated and refined existing conceptual frameworks and used evaluations in UK schools of a range of health promotion topic areas to specify key context-mechanism-outcome configurations. These configurations are presented in a narrative designed to facilitate decision-makers’ and practitioners’ use of the findings in conjunction with knowledge of their local contexts. In this way, we have extended the work of Greenberg et al. [ 32 ] and Samdal and Rowling [ 5 ] by moving beyond statements about the principles of good implementation practice and towards a more refined understanding of the complexity of implementation within educational, public health, and social systems that are constrained in multiple, setting-specific ways.

Our findings have identified key transferable mechanisms (e.g. reciprocity) that impact on implementation and which apply to both teachers and pupils. We have also been able to specify how an accepted principle of implementation, such as congruence between existing school activities and proposed health promotion activities, can operate differently (but beneficially) according to context—for example, by meeting unmet needs, complementing existing activities, or paradoxically by stimulating change so that congruence is achieved. Our findings have also identified where some of the mechanisms that underpin implementation differ in how they operate between primary and secondary schools and between health promotion topics. By exploring context-mechanism-outcome configurations, we have also been able to go beyond generic ‘one recommendation fits all’ statements. For example, we have been able to specify the actions that senior school figures should take in order to provide support for the implementation of a health promotion programme.

Whilst our synthesis provides greater specificity in relation to preparing for implementation and initial implementation of health promotion programmes in schools, the amount, depth, and rigour of evidence about the later stage of embedding into routine practice and the cross-cutting theme of adaptation and evolution (Fig.  2 ) were limited. This meant that we were unable to explore important areas identified in our programme theory relating to embedding into routine practice. For example, we were unable to locate evidence about how different stakeholders’ goals are reconciled; how stakeholders’ enthusiasm, knowledge, and experience are harnessed; and how knowledge about core and customisable elements of programmes are retained in the longer term. An explanation for this is that the timeframe over which evaluations are funded simply do not extend sufficiently far to investigate these factors. Nevertheless, some of the key mechanisms and contexts identified as relevant to the initial implementation of programmes may also be important for longer term embedding or ‘scaling up’ from school to school.

Regarding adaptation and evolution, the planned content and delivery of a number of the programmes evaluated were under-specified, meaning that assessment of fidelity and judging the extent to which (or justification for) adaptation of programmes took place was highly problematic. Tailoring of programmes to meet the needs of participants, both those who deliver a programme (for example, addressing specific skill deficits) and the pupils who are its intended beneficiaries (for example, tailoring to different levels of physical, psychological, and social development), whilst preserving the essential functional components of the programme, is a central challenge which we have not been able to address using the evidence located for this review.

Our findings provide a platform for future evaluations of implementation processes in schools. For example, whilst we have identified the impact of a wide range of stakeholders about the content and delivery of a SRE programme, we were unable to locate evidence about this for other types of health promotion programmes. SRE programmes may represent a distinct, and in some communities particularly contentious, area of health promotion. However, in the absence of research about how stakeholders impact on the implementation of other types of health promotion programmes, we do not know if the mechanisms in operation are the same or different.

Whilst we could, as the review’s authors, speculate about more specific recommendations for public health programme designers, promoters, deliverers, and evaluators, we believe we are not best placed to do this—especially as what may be a salient and useful insight for one group of potential research users (such as head teachers or school governors) may be seen as irrelevant or obvious to another group (such as programme developers and promoters). For this reason, we have undertaken another consultation exercise with representatives of these different groups, which will lead to tailored evidence summaries and recommendations for these different key groups, including commissioners and funders of public health programmes.

Strengths and limitations

This realist review has drawn on a range of types of evidence about implementing health promotion programmes in schools to produce new insights that are relevant to a range of decision-makers. Using a realist approach has provided a consistent logic of inquiry for synthesising evidence across different types of programmes. Through our provision of extensive review process documentation, we hope to enable other reviewers to judiciously apply a realist approach, as well as provide substantive material for critiques that will foster methodological development.

Whilst we have been able to identify context-mechanism-outcome configurations (such as reciprocity) in depth for certain aspects of implementation, this was not the case for all aspects. These differences reflect the extent and depth of the underlying evidence but also, quite simply, the difficulty of identifying ‘hidden’ mechanisms. For those embarking on realist reviews now, it is worth contemplating that we could have widened our searches to other fields, included evaluations from outside of the UK, and/or drawn more closely on our review advisory group’s knowledge to help identify context-mechanism-outcome configurations in these more ‘difficult’ areas.

The notable lack of evidence about what determines the longer term sustainability of programmes (i.e. their embedding in schools year on year), or their ‘spread’ from school to school, may require comparative primary research, for example, comparing effective programmes which have become widespread within some countries (like the ASSIST programme in Wales and England; see University of Bristol’s REF 2014 impact statement [ 40 ] for a description of the impressive uptake of this programme) with others which, whilst found to be effective, never became widely adopted. This may reveal further how different schools or different school systems either complement or conflict with the practicalities of delivering particular programmes. Such research may also reveal whether longer term implementation may rely on stable organisational and budgetary boundaries, together with more compelling evidence of cost-effectiveness—or other factors which would probably not be revealed by initial evaluations in relatively few schools, when subsidised by evaluation funding and often also energised by the original developers of the programme.

Through applying a realist approach, we have been able to identify mechanisms in action that affect the successful implementation of health promotion programmes in schools. At the preparatory stage, implementation hinges on negotiation about programme delivery and the acceptability (or otherwise) of the programme to those who will deliver it. Addressing fears about programme novelty, contentious subject matter, and the extent of support for delivery are likely to be important. At the initial implementation stage, programme delivery needs to be both facilitated within a school and protected from external forces. This becomes more important where the composition of groups of pupils is more complex and where more contentious health issues are addressed. The available evidence was insufficient for us to confidently identify mechanisms about the process of embedding programmes into practice or the circumstances where the adaptation and evolution of programmes is necessary for them to be feasible and sustainable.

Our inclusion of a diversity of sources of information and integration of a review advisory group’s input throughout the review have enabled us to produce findings that are both academically rigorous and applicable to decision-making at a range of local and strategic levels. Further research should focus more on investigating and refining the identified mechanisms (both in trials of interventions and evaluations of local practice), the dynamic nature of programme adaptation during implementation, and programme sustainability.

Availability of supporting data

The data sets supporting the results of this article are included within the article and its additional files.

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Acknowledgements

This project was funded by the NIHR School for Public Health Research (SPHR). The NIHR SPHR is a partnership between the Universities of Sheffield, Bristol, Cambridge, and UCL; The London School for Hygiene and Tropical Medicine; The University of Exeter Medical School; the LiLaC collaboration between the Universities of Liverpool and Lancaster and ‘Fuse’; and The Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland, and Teesside Universities.

The NIHR SPHR commissioned the research following peer review but, otherwise, had no involvement in the design or analysis of the research. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

Thanks are due to our review advisory group for their input and critique throughout the review and to Rebecca Abbott (NIHR CLAHRC South West Peninsula) for valuable feedback on the presentation of this paper. The incisive feedback from the two peer reviewers of this paper helped to significantly improve its methodological clarity and presentation.

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The authors declare that they have no competing interests.

Authors’ contributions

MP wrote the first and subsequent drafts of this manuscript, with comments from RC and RA, and then the remaining authors. RA, KW, TF, and CA conceptualised the study. MP, RA, KW, TF, and CA designed the study. MP, RC, and RA conducted data analysis and interpretation, with additional input to data interpretation by KW, TF, and CA. HW designed and conducted the database searches. All authors read and approved the final manuscript.

Additional files

Additional file 1:.

Search strategy. The file is a record of (and reasons for) the sources obtained. (DOCX 20 kb)

Additional file 2:

Contribution of conceptually rich studies. A total of 22 sources informed the development of the conceptual framework and theory-development review phase. (DOCX 30 kb)

Additional file 3:

Long list of programme theories. The file contains a list of 12 programme theories that encompassed all of the concepts around implementation identified in the 22 conceptually rich sources and to identify the unique contributions of each source. (DOCX 17 kb)

Additional file 4:

review advisory group. The RAG was formed to contribute to the identification, selection, and refinement of programme theories to be tested in the review. (DOCX 24 kb)

Additional file 5:

Contribution of sources to development of programme theories. The file is a documentation of the three stages of programme theory development, showing the areas in which different sources contributed. (DOCX 23 kb)

Additional file 6:

Programme descriptions. The file reports the full details of each programme. (DOCX 26 kb)

Additional file 7:

Critical appraisal summary. A summary of the key points of the critical appraisal collated in a summary critical appraisal table. (DOCX 21 kb)

Additional file 8:

Data extraction tables. The file lists information on study type, the programme being evaluated, the content and delivery of the programme, and research methods (sample, participants, data collection and analysis) and evidence to enable testing of each of the four programme theories. (DOCX 24 kb)

Additional file 9:

Markers of implementation. Our decision-making was guided by looking for ‘markers of implementation’, although we did not limit extracted data to only these ‘markers’ if we judged other evidence to be relevant. (DOCX 19 kb)

Additional file 10:

Practical stages of the synthesis. The file lists the details of the practical stages of the synthesis. (DOCX 17 kb)

Additional file 11:

Long version of synthesis. The file contains a long version of the findings, with examples and greater detail about the rigour of individual pieces of evidence used in the synthesis. (DOCX 84 kb)

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Pearson, M., Chilton, R., Wyatt, K. et al. Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom. Implementation Sci 10 , 149 (2015). https://doi.org/10.1186/s13012-015-0338-6

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• Health promotion in schools
• Implementation
• Realist review
• Public health

Implementation Science

ISSN: 1748-5908

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Coordinated school health programs and academic achievement: a systematic review of the literature

Affiliation.

• 1 Behavioral Sciences, Center for Health Promotion and Prevention Research, The University of Texas Prevention Research Center, UT-Houston School of Public Health, Houston, TX 77030, USA. [email protected]
• PMID: 17970862
• DOI: 10.1111/j.1746-1561.2007.00238.x

Background: Few evaluations of school health programs measure academic outcomes. K-12 education needs evidence for academic achievement to implement school programs. This article presents a systematic review of the literature to examine evidence that school health programs aligned with the Coordinated School Health Program (CSHP) model improve academic success.

Methods: A multidisciplinary panel of health researchers searched the literature related to academic achievement and elements of the CSHP model (health services, counseling/social services, nutrition services, health promotion for staff, parent/family/community involvement, healthy school environment, physical education, and health education) to identify scientifically rigorous studies of interventions. Study designs were classified according to the analytic framework provided in the Guide developed by the Community Preventive Services Task Force.

Results: The strongest evidence from scientifically rigorous evaluations exists for a positive effect on some academic outcomes from school health programs for asthmatic children that incorporate health education and parental involvement. Strong evidence also exists for a lack of negative effects of physical education programs on academic outcomes. Limited evidence from scientifically rigorous evaluations support the effect of nutrition services, health services, and mental health programs, but no such evidence is found in the literature to support the effect of staff health promotion programs or school environment interventions on academic outcomes.

Conclusions: Scientifically rigorous evaluation of school health programs is challenging to conduct due to issues related to sample size, recruitment, random assignment to condition, implementation fidelity, costs, and adequate follow-up time. However, school health programs hold promise for improving academic outcomes for children.

Publication types

• Research Support, U.S. Gov't, P.H.S.
• Systematic Review
• Asthma / prevention & control*
• Child Health Services*
• Child Welfare
• Educational Status*
• Health Education
• Interpersonal Relations
• Mental Health Services
• Physical Education and Training
• School Health Services*

Grants and funding

• U48/CCU609653/PHS HHS/United States
• U48/CCU610818-07/PHS HHS/United States

Schools and Health: Our Nation's Investment (1997)

Chapter: 6 challenges in school health research and evaluation, 6 challenges in school health research and evaluation, overview of research and evaluation.

One of the primary arguments for establishing comprehensive school health programs (CSHPs) has been that they will improve students' academic performance and therefore improve the employability and productivity of our future adult citizens. Another argument relates to public health impact—since one-third of the Healthy People 2000 objectives can be directly attained or significantly influenced through the schools, CSHPs are seen as a means to reduce not only morbidity and mortality but also health care expenditures. It is likely that the future of CSHPs will be determined by the degree to which they are able to demonstrate a significant impact on educational and/or health outcomes.

Evaluation of any health promotion program poses numerous challenges such as measurement validity, respondent bias, attrition, and statistical power. The situation is even more challenging for CSHPs, for several reasons. First, these programs comprise multiple, interactive components, such as classroom, family, and community interventions, each employing multiple intervention strategies. Therefore, it is often difficult to determine which intervention components and specific messages, activities, and services are responsible for observed treatment effects. Second, given the broad scope of CSHPs, it is difficult to determine what the realistic outcomes should be, and measuring these outcomes in school-age children (be it the actual behavior or precursors such as communication skills) is often problematic, especially when outcomes have to do

with such sensitive matters as drug use or sexual behavior. Finally, though some aspects of a CSHP (e.g., classroom curricula) can be replicated, many aspects of the CSHP (e.g., staffing patterns, local norms, and community resources) differ across schools, cities, states, and regions. Consequently, the results of even the most rigorous evaluations may not be generalizable to other settings.

This chapter examines these and other issues related to the evaluation of CSHPs. First, general principles of research and evaluation, as applied to school health programs, are reviewed. Then the challenges and difficulties associated with research and evaluation of comprehensive, multi-component programs are examined. Finally, the difficulties and uncertainties related to research and evaluation of even a single, relatively well-defined component of comprehensive programs—the health education component—are be considered. The committee felt that it was appropriate to focus on health education in this chapter, because of the relative maturity of research in this area. Specific aspects of health education research have been chosen that highlight challenges in evaluating school-based interventions, as well as in interpreting ambiguous, if not conflicting, results relevant to other components of the comprehensive program. Discussion of the research and evaluation of other components of CSHPs—health services, nutrition or foodservices, physical education, and so forth—is found in the general discussion of these components in earlier chapters.

Types of School Health Research

Research and evaluation of comprehensive school health programs can be divided into three categories: basic research, outcome evaluation, and process evaluation.

Basic Research

An ultimate goal of CSHPs is to influence behavior. Basic research in CSHPs involves inquiry into the fundamental determinants of behavior as well as mechanisms of behavior change. Basic research includes examination of factors thought to influence health behavior—such as peer norms, self-efficacy, legal factors, health knowledge, and parental attitudes—as well as specific behavior change strategies. Basic research often employs epidemiologic strategies, such as cross-sectional or longitudinal analyses, as well as pilot intervention studies designed to isolate specific behavior change strategies, although often on a smaller scale than full outcome trials. A primary function of basic behavioral research is to in-

form the development of interventions, whose effects can then be tested in outcome evaluation trials.

Outcome Evaluation

Outcome evaluation includes empirical examination of the impact of interventions on targeted outcomes. Possible outcomes (or dependent variables) include health knowledge, attitudes, skills, behaviors, biologic measures, morbidity, mortality, and cost-effectiveness. Interventions (or independent variables) include specific health education curricula, teaching strategies, organizational change, environmental change, or health service delivery models. This type of evaluation in its most basic form resembles the randomized clinical trial with experimental and control groups, along with the requisite null hypothesis assumptions and concern for internal and external validity. Outcome evaluation can further be divided into three stages: efficacy, effectiveness, and implementation effectiveness trials (Flay, 1986).

Efficacy . Efficacy testing involves the evaluation of an intervention under ideal, controlled implementation conditions. During this stage, for example, teachers may be paid to ensure that they implement a health curriculum, or other motivational strategies may be used to ensure fidelity. The goal of efficacy testing is to determine the potential effect of an intervention, with less concern for feasibility or replicability. In drug study parlance, during this stage of research efforts are made to ensure that the ''drug" is taken so that biologic effects, or lack thereof, can be attributed to the drug rather than to degree of compliance.

Effectiveness . In effectiveness trials, interventions are implemented under real-world circumstances with the associated variations in implementation and participant exposure. Effectiveness trials help determine if interventions can reliably be used under real-world conditions and the extent to which effects observed under efficacy conditions are reproduced in natural settings. Some programs, despite being efficacious, may not be effective if they are difficult to implement or are not accepted by staff or students. Effectiveness research is of particular concern because the results of efficacy testing and, to a lesser extent, of effectiveness trials may not always be generalizable to the real world.

Implementation Effectiveness . In implementation effectiveness trials, variations in implementation methods are manipulated experimentally and outcomes are measured (Flay, 1986). For example, the outcomes can be compared when a CSHP is implemented with or without a school

coordinator or when a health education program is implemented by peers rather than adults.

Process Evaluation

Once an intervention has demonstrated adequate evidence for efficacy and effectiveness, it can be assumed that replications of the intervention will yield effects similar to those observed in prior outcomes research trials. The validity of this assumption is enhanced when multiple effectiveness trials have been successfully conducted under varying conditions and the intervention is delivered with fidelity in a setting and with a target population similar to those used in the initial testing.

It is at this point that process evaluation becomes the desired level of assessment. The goal of process evaluation is not to determine the basic impact of an intervention but rather to determine whether a proven intervention was properly implemented, and what factors may have contributed to the intervention's success or failure at the particular site. Implementation and/or participant exposure can be used as proxies for formal outcome evaluation. Key process evaluation strategies include implementation monitoring (e.g., teacher observation), quality assurance, and assessing consumer reactions (e.g., student, teacher, and parent response to the program).

Evaluation at this level may include some elements of outcome evaluation. Desired outcomes are often stated as objectives to be achieved by the program, which can be evaluated pre- and post-intervention, and may include a comparison group or references to normative data. Random selection and assignment of participants are typically not employed, however, and the level of rigor used to collect and analyze data is often less stringent than in formal outcome evaluation. This type of evaluation is sometimes referred to as program evaluation.

Although program evaluation can include rigorous design and analyses, in many real world program evaluations the assessment is often secondary to the intervention. Such interventions often do not bother with randomized design, control groups, or complex statistics. The evaluation is adapted to the intervention, rather than the inverse. For example, pragmatic issues, more than experimental design, often determine sample size and which sites are assigned to treatment or comparison conditions. In basic research and outcome evaluation on the other hand, evaluation is the principal reason that the intervention is being conducted; pragmatic issues often yield to methodologic concerns, and evaluation procedures largely are determined prior to initiating intervention activities.

Linking Outcome and Process Evaluations

Although outcome and process evaluation are described above as being sequential, the two often are conducted concurrently by linking process data to outcome data in order to determine causal pathways. One application of linking process and outcome data is the dose–response analysis—measuring the relationship between intervention dose and level of outcomes. For example, student behavioral outcomes can be examined relative to levels of teachers' curriculum implementation in a health education study or to students' level of clinic usage in a health services study. A positive dose–response relationship is seen as evidence for construct validity—that is, observed outcomes are attributed to the intervention rather than to other influences. Numerous health education studies have established a dose–response relationship between curriculum exposure and student outcomes (Connell et al., 1985; Parcel et al., 1991; Resnicow et al., 1992; Rohrbach et al., 1993; Taggart et al., 1990). Less is known about dose–response in other components of CSHPs.

Who Conducts the Research?

The various types of school health research are conducted by a diverse group of professionals. Basic research and outcome evaluation are typically conducted by doctoral-level professionals from university and freestanding research centers, often with funding from the federal government (though such studies also are supported by private foundations or corporations). Evaluating CSHPs at the level of basic research or outcome evaluation is largely beyond the fiscal and professional capacity of most local and even state education agencies. Process evaluation, on the other hand, can be conducted by local education agencies, perhaps in partnership with local public health agencies. Many models of CSHPs include an evaluation component, and it is important to delineate what type of evaluation schools and education agencies should reasonably be expected to conduct on the local level.

Although carried out by research professionals, basic research and outcome evaluation should not be abstract academic pursuits that are an end in themselves. Greater interaction is needed between researchers and those who actually implement programs. It would be desirable to stimulate and support research and evaluation alliances among colleges of education, schools of public health, and college of medicine. Bringing together the expertise from all three sectors in school health research and evaluation centers may enhance the understanding and interaction between these sectors and produce research and evaluation methods that can address cross-sector issues more accurately. This also will lead to

developing programs that can be disseminated more easily and to reducing the number of researchers working in isolation.

Uses for Research and Evaluation

Basic research, outcome evaluation, and process evaluation are also conducted for different audiences and intentions. The first two are largely intended to build scientific knowledge and are generally published in the peer-reviewed literature. The latter generally is used to demonstrate feasibility of an intervention, as well as to document the facts that program implementation objectives were met and funds were properly spent. Such reports are typically requested by or intended for state education agencies, local education agencies, or funding sources that may have sponsored the local project. Local program evaluations of pilot programs also are used to justify expanding dissemination efforts.

All three types of evaluation can contribute to the development and dissemination of comprehensive school health programs, although it is important that they be applied in their proper sequence. Process evaluation studies are inappropriate for demonstrating intervention efficacy or measuring cost-effectiveness, just as basic research approaches may go beyond what is necessary for local program evaluation. To merit dissemination, programs should first undergo formal experimental efficacy and effectiveness testing; lower standards may result in adoption of suboptimal programs and ultimately impair the credibility of school health programs among their educational and public health constituencies (Ennett et al., 1994).

METHODOLOGICAL CHALLENGES

Although traditional experimental studies using control or comparison groups are appropriate for testing individual program components and specific intervention strategies, this may not be the case for the overall CSHP, which is a complex entity and varies from site to site. In a recent discussion of methods to evaluate such complex systems as CSHPs, Shaw (1995) proposed that the use of the classic experimental design to conduct outcome evaluations may be outmoded and inadequate for several reasons. First, the randomized clinical trial, with its tightly controlled and defined independent and dependent variables, cannot measure and capture large-scale, rapidly changing systems. Traditional experimental design ignores the need for timely formative descriptive data, maintains the artificial roles of the researcher as external expert and the subject as passive recipient of a defined treatment, and fails to recognize the complex nature of multifaceted programs that vary according to community needs.

Furthermore, there may be ethical dilemmas in randomly assigning students to treatment versus control groups when children's health and well-being are at stake.

It will be difficult—and possibly not feasible—to conduct traditional randomized trials on entire comprehensive programs. However, interventions associated with individual program components should be developed and tested by using rigorous methods that involve experimental and control groups, with the requisite concern for internal and external validity. In this section, some of the methodological challenges of demonstrating program impacts are examined.

Challenges in Assessing Validity

A goal of studying CSHPs at the level of efficacy testing is to measure the extent to which programs produce the desired outcomes (internal validity)—that is, to determine whether there is a causal relationship between the independent variable (CSHP) and defined outcomes such as knowledge, health practices, or health status.

Defining the Independent Variable

The first measurement challenge is the difficulty in defining the independent variable (the CSHP) or "treatment." Knapp (1995) has described this dilemma: "The 'independent variable' is elusive. It can be many different kinds of things, even within the same intervention; far from being a fixed treatment, as assessed by many research designs, the target of study is more often a menu of possibilities."

Ironically, the most successful programs—which are, in fact, comprehensive, multifaceted, interdisciplinary and well integrated into the community—may be the most difficult to define and segregate into components readily identifiable as the independent variable. It may be impossible, for example, to separate effects of the school from those of the community (Perry et al., 1992). This poses an important assessment dilemma. While it is vital that comprehensive programs be evaluated as a whole (Lopez and Weiss, 1994), it is unlikely that any individual program could be replicated in its entirety in a different community with its varying infrastructure, needs, and values. Thus, internal validity—the extent to which the effectiveness of the entire program is being accurately measured—may be high, but external validity—the extent to which the findings can be generalized and replicated beyond a single setting—is sacrificed.

Because of limited resources, one might wish to prioritize individual program components based on their relative efficacy. However, the over-

all effect of comprehensive programs may well be more than or different from the sum of its parts. Using a factorial design to examine the effects of individual components or combinations of components would require an unwieldy number of experimental conditions and large sample size. Thus, the independent variables in a CSHP not only may be difficult to define and measure, but it is unlikely that a consensus of what should comprise the intervention can or even should be reached.

Defining the Dependent Variable

In similar ways, defining the appropriate, feasible, and measurable outcomes (dependent variables) of a CSHP is equally challenging. Is it necessary to use change in health-related behaviors, such as smoking or drug use, to measure effectiveness of health education programs, or is the acquisition of knowledge and skills sufficient? If behavior change outside the school is required to declare effectiveness, this would seem to represent an educational double standard. For example, the quality and effectiveness of mathematics education are measured by determining mathematics knowledge and skills, using some sort of school-based assessment, not by determining whether the student actually balances a checkbook or accurately fills out an income tax form as an adult. Likewise, the quality of instruction in literature or political science is measured by the acquisition of knowledge, not by whether the student writes novels, reads poetry, votes, or becomes a contributing citizen.

Similarly, should appropriate outcomes for school health services be improved health status, behaviors, and long-term health outcomes, or is simply access to and utilization of services a sufficient end point? Is a reduction in absenteeism a proxy for improved health status and a reasonable indicator of health outcomes? Dependent variables used to measure effectiveness of school-linked health services have included linking students with no prior care to health services, decreased use of the emergency room for primary care, identification of previously unidentified health problems, access to and utilization of services by students and families, perceptions and health knowledge of students and their parents, decreasing involvement in risk behaviors, and health status indicators (Glick et al., 1995; Kisker et al., 1994; Lewin-VHI and Institute of Health Policy Studies, 1995). Some of these measures simply determine whether school services provide access and utilization, whereas other measures look for a change in health status and behavior. However, if improved health status and behaviors are declared to be the expectation for school health services, does this hold the school to higher standards than those of other health care providers?

The committee points out that, although influencing health behavior

and health status are ultimate goals of CSHPs, such end points involve personal decisionmaking beyond the control of the school. Other factors—family, peers, community, and the media—exert tremendous influence on students, and schools should not bear total responsibility for students' health behavior and health status. Schools should be held accountable for conveying health knowledge, providing a health-promoting environment, and ensuring access to high-quality services; these are the reasonable outcomes for judging the merit of a CSHP. 1 Other outcomes—improved attendance, better cardiovascular fitness, less drug abuse, or fewer teen pregnancies, for example—may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by personal decisionmaking and factors beyond the control of the school. In particular, null or negative outcomes for these measures should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence on children and young people oppose and outweigh the influence of the CSHP.

Other Issues

In addition to the above difficulties, all of the potential biases and challenges inherent in any research also apply. Serious threats to validity in measuring effects of CSHP include:

the Hawthorne effect—positive outcomes simply due to being part of an investigation, regardless of the nature of the intervention;

self-reporting biases—responding with answers that are thought to be "correct" and socially desirable;

Type III error—incorrectly concluding that an intervention is not effective, when in fact ineffectiveness is due to the incorrect implementation of the intervention.

ensuring even and consistent distribution of the intervention;

sorting out effects of confounding and extraneous variables;

isolating effective ingredients of multifaceted programs;

control groups that are not comparable;

differential and selective attrition in longitudinal studies;

inadequate reliability and validity of measurement tools; and

vague or inadequate conceptualization of study variables.

Another problem in drawing conclusions from reported research is "reporting bias"—the fact that only positive findings tend to be reported in the literature while studies with negative or inconclusive results are not often published. It is also important to remember that results that are statistically significant may not always have educational and public health significance.

Challenges Related to Feasibility

The kinds of large-scale research studies necessary to assess long-term outcomes of CSHPs are extremely costly and require extensive coordination. Since such programs are usually implemented for entire schools, communities, regions, or states, a majority of the children who participate are at relatively low risk for a number of outcomes of potential relevance. In addition, often only small to moderate outcome effects are sought. Hence, sample size needs are large, particularly when the unit of measurement is the school or the community rather than the individual.

Once efficacy and effectiveness have been demonstrated, the problem of developing a feasible program evaluation plan is compounded by the lack of evaluation expertise at the local or regional level and the inadequate or incompatible information systems for collecting, analyzing, and disseminating information. Local planners often need assistance in selecting and implementing evaluation strategies and in identifying means to make existing data more useful. For school health education, there are numerous guidelines and evaluation manuals from the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Service's Center for Substance Abuse Prevention at the Substance Abuse and Mental Health Services Administration, and the Educational Development Center, to help states develop an evaluation plan. The national evaluation plan for the Healthy Schools, Healthy Communities Program provides helpful information for the evaluation of school health services (Lewin-VHI and Institute of Health Policy Studies, 1995). This plan is facilitated by a standardized data collection system and marks the first time that health education and health services will be systematically analyzed with a management information system that records different types of health education interventions, utilization of health services, and outcomes.

CHALLENGES AND FUTURE DIRECTIONS FOR SCHOOL HEALTH EDUCATION RESEARCH

Health education is one of the essential components of CSHPs. As

described in earlier chapters, health instruction has taken place in schools for many years, and the field is reasonably well defined and developed compared to some of the other aspects of a CSHP. Health education research has been an active field, but considerable knowledge gaps exist and research findings are often ambiguous, unexpected, or sometimes seemingly contradictory. This section focuses on some of the challenges and unresolved questions in classroom health education and suggests issues that merit further study.

Effects of Comprehensive Health Education

The preponderance of school health education research has consisted of outcome evaluations focusing on categorical risk behavior, such as smoking, drug use, sexual behavior, and nutrition. A few notable studies have examined several risk behaviors simultaneously—such as nutrition, physical activity, and smoking—as risk reduction interventions for cardiovascular disease or cancer (Luepker et al., 1996; Resnicow et al., 1991) or have looked at efforts to prevent drug, alcohol, and tobacco abuse (Pentz, 1989a), but there have been very few studies that evaluate comprehensive, multitopic health education programs (Connell et al., 1985; Errecart et al., 1991). The lack of evaluation studies of comprehensive health education is to a large extent the result of how school health research has been funded at the federal level. Generally, health concerns are divided into categorical areas for research and demonstration funding; the result is that funding agencies are interested in funding only research and development projects that address their particular disease area of responsibility. There is a scarcity of hard data about the potential impact of overall comprehensive classroom health education programs. Only a few commercially available multitopic school health curricula have been evaluated to test their effectiveness (e.g., the Know Your Body program). Some of these either are old and or have not made use of the methods demonstrated to be effective in categorical research and demonstration projects, which means that schools are faced with adopting programs that have not been evaluated or attempting to piece together evaluated programs.

How Much Health Education Is Enough?

There is consensus that health education programming should span kindergarten through grade 12 (Lohrman et al., 1987). However, the precise number and sequence of lessons required to achieve significant enduring effects have not been clearly defined. As mentioned previously, such determinations are complicated by uncertainties in what end points

are desirable or feasible—behavior change versus change in knowledge and attitudes. If the desired end point is change in behavior, a greater dose will likely be required. ("Dose" involves two dimensions: intensity, or amount of programming per year, and duration, the number of years of programming.) Moreover, if the end point is long-term behavior change or reductions in adult morbidity and mortality, an even greater dose may be necessary that provides more intensive programming for a longer time.

The ideal means to determine adequate dose would be to deliver the same curriculum using various levels of intensity and duration and then examine differences in student outcomes by differences in curriculum exposure. However, few studies have been designed a priori to test varying format and amount of programming. Instead, most of the evidence derives from post hoc analyses examining dose–response effects between health education programming and student outcomes—that is, the relationship between level of student outcomes and how much intervention students actually received. Despite the methodologic limitations, establishing a dose–response relationship from post hoc analysis is helpful for two reasons. First, a positive dose–response relationship provides evidence for construct validity—observed changes can be attributed to the health education program rather than to other variables. Second, results of these analyses have implications regarding the proper amount and sequence of health education programming.

One of the first major studies to demonstrate a dose–response effect was the School Health Education Evaluation project (Connell et al., 1985). Students from classrooms in which health programs were implemented more fully demonstrated significantly greater improvements in attitude and behaviors, compared to the entire intervention cohort. In addition, students exposed to two years versus one year of programming showed considerably greater changes in attitudes and practices. With regard to specific dose, there was evidence that between 15 and 20 hours of classroom instruction was required to produce meaningful student effects.

Dose–response effects were also evident in the Teenage Health Teaching Modules evaluation. This study found that changes in health knowledge as well as some priority health behaviors were related to teacher proficiency and to how well teachers adhered to the program materials, although these effects were somewhat equivocal (Parcel et al., 1991). In a third study, a three-year evaluation of the Know Your Body program, Resnicow et al. (1992) found significantly larger intervention effects for blood lipids, systolic blood pressure, health knowledge, self-efficacy, and dietary behavior among students exposed to "high-implementation" teachers relative to moderate- and low-implementation teachers, as well as to comparison youth receiving no programming.

There is additional evidence regarding dose–response from a survey conducted for the Metropolitan Life Insurance Company in 1988. This survey of 4,738 students in grades 3 through 12 in 199 public schools revealed that as the years of health instruction increased, students' health-related knowledge and healthy habits increased. With one year of health instruction, 43 percent of the students drank alcohol ''sometimes or more often," a level that decreased to 33 percent for students who had received three years of health instruction. With only one year of health instruction, 13 percent of the students had taken drugs, compared with only 6 percent who had received three years of health instruction. In regard to exercising outside of the school, 80 percent of the students who had three years of health instruction did so, but only 72 percent of those who had one year of instruction exercised outside of school (Harris, 1988).

Duration, Sequence, and Timing of Health Education

Two other aspects of dose include intensity of programming (i.e., concentrated versus dispersed) and booster treatments. With regard to the former, Botvin and colleagues (1983) found that students who received a substance use education program several times a week for 4 to 6 weeks (a "concentrated" format) showed stronger treatment effects than youth receiving the program once a week for 12 weeks (a "dispersed" format). Additionally, in two separate studies, students receiving booster sessions following a year of primary intervention showed larger and more sustained behavior effects than youth receiving only the initial intervention (Botvin et al., 1983; Botvin et al., 1995). Taken together, these findings suggest that the greater the intensity and duration of health education programming, the greater is the effect. It is important to note that "increased dose" can include two elements. The first relates to the number of lessons contained in a curriculum; the second is a function of implementation fidelity on the part of classroom teachers. Thus, a complex, non-user-friendly health education program containing many lessons may, due to low teacher implementation, result in a lower dose than will a more user-friendly program containing fewer lessons.

With regard to specific policy recommendations, there are insufficient data to delineate a requisite number of lessons across content areas and grades. There is, however, some evidence to suggest that at least 10 to 15 initial lessons, plus 8 to 15 booster sessions in subsequent years, are required to produce lasting behavioral effects (Botvin et al., 1983, 1995; Connell et al., 1985). These data, however, are derived primarily from substance use prevention studies of middle school youth. Little is known about the requisite intensity and duration of programming for other content areas or other age groups. It is also unclear to what extent general life

skills training, which targets substance use or sexual risk behaviors, may positively influence other behavioral domains. If spillover, synergistic effects from skills training or other common elements of health education programs (e.g., modifying normative expectations and increasing self-efficacy) occur when categorical programs are delivered within a comprehensive framework, the total number of lessons ultimately required for comprehensive curricula may be fewer than the sum of lessons from isolated categorical programs.

Additionally, whether these findings, which are based on a categorical topic, can be applied to a comprehensive curriculum merits discussion. It may be necessary to stagger content across K–12 and to target programming by developmental needs. For example, programming could be concentrated more heavily on substance use prevention at the middle school level, while in primary grades, nutrition and safety education could comprise the areas of focus. This developmental needs approach is a deviation from currently proposed curriculum frameworks, which suggest that health education address 8 to 12 content areas at each grade level. In view of the research that suggests a minimal number of lessons per grade for each content area, more serious attention should be given to setting priority areas for each stage of student development.

Lasting Effects of School Health Education

In several long-term follow-up studies of substance prevention programs delivered in grades 5 through 8 (Bell et al., 1993; Flay et al., 1989; Murray et al., 1989), positive program effects observed one to four years following the intervention had decayed by grade 12, or shortly after graduation from high school. Decay of program effects has also been observed for curricula addressing other content areas (Bush et al., 1989). There are studies, however, in which behavioral effects decayed but significant effects for knowledge and attitude were maintained (Bell et al., 1993; Flay et al., 1995).

Recently, however, Botvin and colleagues (1995) reported positive long-term results in a study involving more than 3,500 students in grade 12 who were randomly assigned to receive either the Life Skills Training substance use prevention program in grades 7 through 9 or "treatment as usual." Significant reductions in tobacco, alcohol, and marijuana use were evident at the follow-up in grade 12, and effects were greater among students whose teachers taught the program with higher fidelity (i.e., high implementors).

How can the positive effects reported by Botvin et al. be reconciled with the null results reported in prior studies? One explanation is dose. The previous interventions comprised only six to eight lessons in the first

year and, in the Ellickson and Bell (1990) and Flay et al. (1989) studies, three to five booster sessions in subsequent years. Botvin's intervention contained 15 lessons in the first year and 15 additional lessons over the next two years. Other explanations include superiority of the Life Skills Training curriculum, including its content, format, and teacher training procedures, as well as higher levels of teacher implementation. Although the results of Botvin's study of substance use prevention are encouraging, research regarding the optimal dose and timing of curricula addressing other health behaviors is still needed. Given that achieving change in language arts and mathematics skills requires daily instruction for 12 academic years, it is reasonable to conclude that changes in health knowledge and in health behaviors also will require more instruction than one semester, the standard middle and secondary school requirement.

Active Ingredients of Health Education

Many successful health education programs employ several conceptually diverse intervention strategies such as didactic, affective, and behavioral activities directed at students, as well as environmental and policy change. Although there is considerable evidence that such programs as a whole can work, the construct validity of specific subcomponents—that is, "why" programs achieve or fail to achieve their desired effects—remains unclear (McCaul and Glasgow, 1985). Consider, for example, skills training. During the 1980s, numerous skills-based interventions aimed at increasing general and behavior-specific skills were developed and evaluated (Botvin et al., 1984; Donaldson et al., 1995; Flay, 1985; Kirby, 1992; McCaul and Glasgow, 1985). While initial results were encouraging and skills training has become an integral component of many school health education programs (Botvin et al., 1980; CDC, 1988, 1994; Flay, 1985; Glynn, 1989; Kirby, 1992; Pentz et al., 1989b; Schinke et al., 1985; Walter et al., 1988), many "skills-based" programs include other intervention strategies, such as modifying personal and group norms and outcome expectations, which also many have contributed to the reported intervention effects (Botvin et al., 1984; Ellickson and Bell, 1990; Murray et al., 1989; Pentz et al., 1989a; Walter et al., 1987). Several studies specifically designed to test the independent effects of skills training have found this approach to be largely ineffective (Elder et al., 1993; Hansen and Graham, 1991; Sussman et al., 1993). Instead, these studies indicate that modifying normative beliefs—students' assumptions regarding the prevalence and acceptability of substance use—appears to be the ''active ingredient" of many of the skills training programs. Despite the questionable effectiveness of skills training in substance use prevention, skills may be important in other behavioral domains such as sexuality, nutrition, and

exercise (Baranowksi, 1989; Perry et al., 1990; Sikkema et al., 1995; St. Lawrence et al., 1995; Warzak et al., 1995).

Similarly, although there is acceptance on the part of many health educators that peers are effective "messengers," the evidence for the effectiveness of peer-based health education is also somewhat equivocal (Bangert-Drowns, 1988; Clarke et al., 1986; Ellickson et al., 1993; Johnson et al., 1986; McCaul and Glasgow, 1985; Murray et al., 1988; Perry et al., 1989; Telch et al., 1990). The effectiveness of peer-based programs is likely to depend more on how peers are included in the program than on simply having peer-led activities.

In a review of programs to reduce sexual risk behavior, Kirby and coworkers found several differences between programs that had an impact on behavior and those that did not (Kirby et al., 1994). Although the authors warn that generalizations must be made cautiously, ineffective curricula tended to be broader and less focused. Effective curricula clearly focused on the specific values, norms, and skills necessary to avoid sex or unprotected sex, whereas ineffective curricula covered a broad range of topics and discussed many values and skills. Interestingly, the length of the program or the amount of skills practice did not appear to predict the success of programs. The authors suggest, however, that skills practice may be effective only when clear values or norms are emphasized or when skills focus specifically on avoiding undesirable sexual behavior rather than on developing more general communication skills.

Given the limited funding and classroom time available for health education, it is important that school health education programs include primarily those approaches known to influence health behavior. Providing health information is a necessary but certainly not sufficient condition for affecting behavior. Identifying "active ingredients" can be achieved through factorial designs as well as post hoc statistical techniques such as structural models, and discriminant analysis can be used to elucidate mediating variables and specific intervention components that may account for program effects (Botvin and Dusenbury, 1992; Dielman et al., 1989; MacKinnon et al., 1991).

Risk-Factor-Specific Versus Problem Behavior Intervention Models

Numerous studies have found that "problem" behaviors—such as the use of alcohol, marijuana, and tobacco; precocious sexual involvement; and delinquent activity—are positively correlated and occur in clusters. Problem Behavior Theory proposes an underlying psychologic phenomenon of "unconventionality" as the unifying etiologic explanation (see Basen-Engquist et al., 1996; Donovan and Jessor, 1985; Donovan et al., 1988; Resnicow et al., 1995). This conceptualization of health behavior has

significant implications for CSHPs. As opposed to commonly used risk-factor-specific interventions that deal with each behavior separately, Problem Behavior Theory suggests that high-risk and problem behaviors can be prevented by an intervention that addresses common predisposing causes. Such interventions may be not only more effective but also more efficient, since fewer total lessons may be required to alter the common "core" causes. In addition to generic interventions, it may also be necessary to apply general strategies to selected high-risk behaviors. However, most school systems do not conceptualize health education from this perspective. Instead, health instruction is broken down into discrete content areas, more akin to the risk-factor-specific approach. Additional research, particularly studies examining the effects of interventions addressing traits that may underlie clusters of risk behaviors, is needed before health education is restructured toward a more targeted model of health behavior change.

Realistic Outcomes for School Health Education

It can be argued that previous studies reporting weak or null behavioral outcomes employed health education interventions of insufficient dose and breadth. Many of the interventions had no more than 10 lessons, delivered over the course of one year, and few or no subsequent booster lessons. As noted earlier, the positive long-term behavioral effects reported by Botvin and colleagues (1995) may be attributed largely to the increased dose. Additionally, had the categorical programs for which no long-term behavioral effects were observed been delivered within the context of a comprehensive school health program, positive effects may have been observed. It is important to set realistic expectations for school health education, particularly since many of the programs used in our schools provide a dose of insufficient intensity and duration, whose effects are further attenuated by inadequate levels of teacher implementation. As stated earlier, although influencing behavior is an ultimate goal of school health education, schools should not bear the total responsibility for student behavior, given all the other influences on students—family, peers, the media, community norms, and expectations—that are beyond the control of the school. Schools should be held accountable for providing a high-quality, up-to-date health education program that is delivered by qualified teachers using curricula that are based on research and have been validated through outcome evaluation. Schools should be held responsible for arming students with the knowledge, attitudes, and skills to adopt health-enhancing behavior and to avoid health-compromising behavior. If these conditions are met but behavioral outcomes are still less than desired, then other sources of influence on students must be exam-

ined for alignment with school health education messages. In addition, there may be delayed effects on behavior in later life, even if no immediate behavioral impacts are observed.

There is encouraging evidence that when school-based interventions are delivered along with complementary community-wide or media campaigns, significant long-term behavioral effects can be achieved (Flynn et al., 1994; Kelder et al., 1993; Perry et al., 1992; see Flay et al., 1995, for an exception). Therefore, although health education delivered in isolation may not be able to produce lasting behavioral effects, when combined with other activities or implemented within a comprehensive school health program, significant enduring changes in behavior as well as physical risk factors can be achieved.

There is considerable evidence that comprehensive curricula can produce significant short-term effects on multiple health behaviors, including substance use, diet, and exercise (Bush et al., 1989; Connell et al., 1985; Errecart et al., 1991; Resnicow et al., 1992; Walter et al., 1988, 1989). However, many of the assumptions regarding the effectiveness of classroom health education derive from studies of categorical programs, and it is unclear to what degree the effects observed for categorical programs are diminished or magnified when taught within a comprehensive framework. Although it can be argued that incorporating categorical programs within a comprehensive framework would attenuate effects because the focus on any one behavior or health issue would be diminished, it could also be argued that program effects would be enhanced because comprehensive programs provide extended if not synergistic application and reinforcement of essential skills across a wide range of topics. This is another area that calls for further research.

SUMMARY OF FINDINGS AND CONCLUSIONS

Research and evaluation of CSHPs can be divided into three categories: basic research, outcome evaluation, and process evaluation. Basic research involves inquiry into the fundamental determinants of behavior as well as mechanisms of behavior change. A primary function of basic research is to inform the development of interventions that can then be tested in outcome evaluation trials. Outcome evaluation involves the empirical examination of interventions on targeted outcomes, based on the randomized clinical trial approach with experimental and control groups. Process evaluation determines whether a proven intervention was properly implemented and examines factors that may have contributed to the intervention's success or failure. Basic research and outcome evaluation are typically conducted by professionals from university or other research centers and are largely beyond the capacity of local education agencies.

The committee believes that process evaluation is the appropriate level of evaluation in local programs.

Research and evaluation are particularly challenging for CSHPs. Since these programs comprise multiple interactive components, it is often difficult to attribute observed effects to specific components or to separate program effects from those of the family or community. Determining what outcomes are realistic and measuring outcomes in students are often problematic, especially when outcomes involve sensitive matters such as drug use or sexual behavior. Furthermore, since CSHPs are unique to a particular setting, the results of even the most rigorous evaluations may not be generalizable to other situations.

Interventions associated with the separate, individual components of CSHPs—health education, health services, nutrition services, and so forth—should be developed and tested using rigorous methods involving experimental and control groups. However, such an approach is likely to be difficult—and possibly not feasible—for studying entire comprehensive programs or determining the differential effects of individual components and combinations of components.

A fundamental issue involves determining what outcomes are appropriate and reasonable to expect from CSHPs. The committee recognizes that although influencing health behavior and health status is an ultimate goal of a CSHP, such end points involve factors beyond the control of the school. The committee believes that the reasonable outcomes on which a CSHP should be judged are equipping students with the knowledge, attitudes, and skills necessary for healthful behavior; providing a health-promoting environment; and ensuring access to high-quality services. Other outcomes—improved cardiovascular fitness or a reduction in absenteeism, drug abuse, or teen pregnancies, for example—may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by factors beyond the control of the school. In particular, null or negative measures for these outcomes should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence oppose and outweigh that of the CSHP or that the financial investment in the CSHP is so limited that returns are minimal.

RECOMMENDATIONS

In order for CSHPs to accomplish the desired goal of influencing behavior, the committee recommends the following:

An active research agenda on comprehensive school health programs should be pursued in order to fill critical knowledge

gaps; increased emphasis should be placed on basic research and outcome evaluation and on the dissemination of these research and outcome findings.

Research is needed about the effectiveness of specific intervention strategies such as skills training, normative education, or peer education; the effectiveness of specific intervention messages such as abstinence versus harm reduction; and the required intensity and duration of health education programming. Evidence suggests that common underlying factors may be responsible for the clustering of health-compromising behaviors and that interventions may be more effective if they address these underlying factors in addition to intervening to change risk behaviors. Additional research is needed to understand the etiology of problem behavior clusters and to develop optimal problem behavior interventions. And finally, since the acquisition of health-related social skills—such as negotiation, decisionmaking, and refusal skills—is a desired end point of CSHPs, basic research is needed to develop valid measures of social skills that can then be used as proxy measures of program effectiveness. Diffusion-related research is critical to ensure that efforts of research and development lead to improved practice and a greater utilization of effective methods and programs. Therefore, high priority should be given to studying how programs are adopted, implemented, and institutionalized. The feasibility and effectiveness of techniques of integrating concepts of health into science and other school subjects should also be examined.

Since the overall effects of comprehensive school health programs are not yet known and outcome evaluation of such complex systems poses significant challenges, the committee recommends the following:

A major research effort should be launched to establish model comprehensive programs and develop approaches for their study.

Specific outcomes of overall programs should be examined, including education (improved achievement, attendance, and graduation rates), personal health (resistance to "new social morbidities," improved biologic measures), mental health (less depression, stress, and violence), improved functionality, health systems (more students with a "medical home," reduction in use of emergency rooms or hospitals), self-sufficiency (pursuit of higher education or job), and future health literacy and health status. Studies could look at differential impacts of programs produced by such factors as program structure, characteristics of students, and type of school and community.

A thorough understanding of the feasible and effective (including

cost-effective) interventions in each separate area of a CSHP will be necessary to provide the basis for combining components to produce a comprehensive program.

The committee recommends that further study of each of the individual components of a CSHP—for example, health education, health services, counseling, nutrition, school environment—is needed.

Additional studies are needed in a number of other areas. First, more data are needed about the advantages (cost and effectiveness) and disadvantages of providing health and social services in schools compared to other community sites—or compared to not providing services anywhere—as a function of community and student characteristics. This information will require overall consensus about the criteria to use for determining the quality of school health programs. It is also important to know how best to influence change in the climate and organizational structure of school districts and individual schools in order to bring about the adoption and implementation of CSHPs. Finally, there is a need for an analysis of the optimal structure, operation, and personnel needs of CSHPs.

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Schools and Health is a readable and well-organized book on comprehensive school health programs (CSHPs) for children in grades K-12. The book explores the needs of today's students and how those needs can be met through CSHP design and development.

The committee provides broad recommendations for CSHPs, with suggestions and guidelines for national, state, and local actions. The volume examines how communities can become involved, explores models for CSHPs, and identifies elements of successful programs. Topics include:

• The history of and precedents for health programs in schools.
• The state of the art in physical education, health education, health services, mental health and pupil services, and nutrition and food services.
• Policies, finances, and other elements of CSHP infrastructure.
• Research and evaluation challenges.

Schools and Health will be important to policymakers in health and education, school administrators, school physicians and nurses, health educators, social scientists, child advocates, teachers, and parents.

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Influence of key components of health-promoting schools and physician ratio on health insurance education: a cross-sectional study

• Original Article
• Published: 11 May 2024

Cite this article

• Chia-Chen Chang   ORCID: orcid.org/0000-0003-2050-5447 1 ,
• Li-Chu Chen 2 ,
• Ping-Hsiu Tsai 3 ,
• Su-Hao Fan 4 &
• Chen-Yin Tung 1  

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Health-Promoting Schools (HPS) have been implemented worldwide for years. However, the influence of healthcare resources, such as physician ratio, on the attitude of students towards healthcare services remains poorly studied. This study evaluated the influence of health information education (HIE) programs on the implementation of HPS key components across various school levels and physician ratios, and explored the relationship between these factors and healthcare attitudes of students.

This cross-sectional study used data from the Health Promoting Schools Performance Survey, which included 3,365 primary and secondary schools.

HIE programs were implemented in 2,525 schools. Primary schools had a higher HIE adoption rate than did secondary schools. HPS key components, including health policy, health life skill, and community relation, were commonly promoted. Schools conducting HIE effectiveness analysis showed significantly better implementation of HPS key components. Physician ratio, personal health life skills of students, community relations, students’ lectures, and teacher empowerment were significantly influenced by HIE. Multiple regression analysis revealed that low physician ratio was associated with an emphasis on the promotion of school health services. In schools with medium and high physician ratios, enhancement of teacher empowerment activities improved HIE.

Conclusions

This study provides important insights on key components of HPS and shows that these can be customized according to physician ratio to enhance the effectiveness of HIE.

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Population Health in the Medical School Curriculum: a Look Across the Country

From Classroom to Community: the Impact of a Non-Clinical Clerkship on Fourth-Year Medical Students’ Ability to Address Social Determinants of Health

Effective health promoting school for better health of children and adolescents: indicators for success, availability of data and materials.

Every year from November to December, school staff in Taiwan are required to complete a survey on health promotion of the Ministry of Education over the past year through the database system. Any queries regarding these data may be directed to the corresponding authors. The datasets generated and/or analyzed during the current study are not publicly available because of the regulations stipulated by the Institutional Review Board of the National Taiwan Normal University’s Research Ethics Review Committee. However, the datasets are available from the corresponding author upon reasonable request.

Abbreviations

Community relations

• Health insurance education

Health-promoting school

Personal health life skill

School social environment

School health policy

School health services

School physical environment

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Acknowledgements

We appreciate the support of the Ministry of Education and National Health Insurance Administration in Taiwan in providing financial assistance and administrative support. We thank all the schools who participated in this study in 2018. We also express our gratitude to the reviewing committee for their valuable insights, which contributed to presenting our findings more comprehensively and clearly.

This study was funded by Ministry of Education, Taiwan.

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Chia-Chen Chang & Chen-Yin Tung

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Li-Chu Chen

Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan

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Department of General Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan

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Conceptualization, CCC; data curation, LCC; formal analysis, PHT; funding acquisition, CYT; investigation, CYT; methodology, CCC; project administration, CCC; resources, LCC; software, PHT; supervision, CYT; validation, SHF; visualization, PHT; writing – original draft, PHT; writing – review and editing, CCC.

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Correspondence to Chen-Yin Tung .

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This study has been approved by the Research Ethics Committee (No. 202006HS010, Research Ethics Committee, National Taiwan Normal University).

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This study was reviewed and approved by the Institutional Review Board of the Research Ethics Review Committee of the National Taiwan Normal University (case number 202006HS010). The entire study was conducted according to the appropriate guidelines and regulations of the country in which it took place.

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Chang, CC., Chen, LC., Tsai, PH. et al. Influence of key components of health-promoting schools and physician ratio on health insurance education: a cross-sectional study. J Public Health (Berl.) (2024). https://doi.org/10.1007/s10389-024-02251-w

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DOI : https://doi.org/10.1007/s10389-024-02251-w

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

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• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133.
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598.
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

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MSIM team uses AI to battle bias in hiring

Flipping through resumes can be a tedious task. Even as the hiring process has digitized, combing through hundreds if not thousands of resumes often is a manual chore that takes hours. Worse, this initial sorting can introduce bias into hiring.

Now a team of graduate students from the University of Washington Information School has developed a possible solution. The team created a program that would use artificial intelligence to extract key points from job descriptions and rank resumes based on those requirements.

The goal would be to match the ideal candidate with the desired experience and skills while eliminating unintentional or even explicit bias. Recruiters would still have a chance to add or reduce the weight of any skill in this initial sorting.

“We're all of diverse backgrounds in America,” said Jin Lee, one of the students. “We felt that we could put our skills to use and actually make a meaningful impact for people — even ourselves — by reducing bias in hiring.”

Other team members are Shinjini Guha, Douglas S. Lew Tan and Jay Kuo. They are all pursuing Master of Science in Information Management degrees. This is their Capstone project, the final, culminating project for many iSchool students. 

They have been working on the project with Seattle startup Included, which aims to build software that embeds diversity, equity and inclusion metrics into its analytics platform. 

Businesses have generally underinvested in human resources departments, said Chandan Golla, Included’s co-founder and chief product officer. Artificial intelligence along with companies such as Included can change that dynamic.

“This is a problem that every company has, whether you are a company of five people or 500,000 people,” Golla said. “Any job you post out there, you do get hundreds of applications. And most of the time the hiring team is small.”

The students started working on the project after connecting with Included at the iSchool’s Capstone Night in October. Part of the task was to narrow the project’s scope to something that would be manageable but meaningful.

Lee took on the role of project manager, Guha led product development, Kuo focused on data science, and Lew Tan worked on user experience research. For the project, the team spoke to two international recruiters, two recruiting agencies and two recruiters at other companies.

“For me, it was a fun process to practice the research methods that I’ve learned and use them in a real-world situation,” Lew Tan said.

The program combs through the job description to match traits with the job applicants, scores each resume and ranks them. The program also allows recruiters to weigh criteria differently. 

“If a master’s degree matters more than years of experience, the recruiter can assign more weight for master’s degree rather than years of experience,” Kuo said. “So, the recruiters can actually play around with all the features to make sure the recruiter gets the best ranking.”

Or as Guha put it: “We’re allowing the recruiters themselves, based on their conversation with the hiring managers and teams, to set importance to different features. … They decide what they call highly qualified.”

One of the challenges that recruiters face is that job applicants can use ambiguous wording on their resumes. For instance, someone who worked for Amazon Web Services could note that on their resume by writing AWS, a common abbreviation for the company, which may stymie a resume-screening program looking for exact matches. 

The team used open-source Mistral AI to be able to interpret unclear passages in resumes, although that’s still a work in progress. Still, Golla said he’s been impressed with the level of work of work from the iSchool students. 

“We are building out the prototypes and the plan is to integrate that into mainstream experiences,” said Golla, who noted this is his company’s first time working with the iSchool and that Included sponsored three teams. 

Guha said she found the experience a great learning opportunity, as she used unfamiliar tools. “Working with a startup is great because you get a lot of freedom to experiment and there’s no restriction on what we can and can’t do,” Guha said. 

Lee said he was proud of what they accomplished, seeing where they started and witnessing the results.

“Part of doing the Capstone project is we should learn how to do our respective roles,” Lee said. “So, I learned a lot of project management skills, especially because I want to go into project management where I work with talented people like Shinjini, Jay and Douglas.”

Pictured at top: From left, Capstone team members Jay Kuo, Jin Lee, Douglas S. Lew Tan and Shinjini Guha.

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Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

1 Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, EX1 2LU UK

2 School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK

R. Anderson

Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children’s and young people’s health. However, understanding of how such programmes can be implemented in schools is more limited.

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

In consultation with the review advisory group, we developed four programme theories ( preparing for implementation , initial implementation , embedding into routine practice , adaptation and evolution ); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity—the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

Conclusions

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0338-6) contains supplementary material, which is available to authorized users.

Schools have long been viewed as a good setting in which to encourage healthy lifestyles and choices amongst children. The practice of health promotion in schools has been reinforced by the World Health Organization’s (WHO) Ottawa Charter for Health Promotion [ 1 ], the lifetime health and well-being benefits for children and communities that are expected to follow [ 2 ], and latterly by research evidence of synergy between health and education [ 3 ]. Schools in many countries aspire to more comprehensive, integrated approaches to health promotion which address both individuals’ attitudes and behaviours and the school environment [ 4 , 5 ]. The WHO concept of health-promoting schools [ 2 , 6 , 7 ], known also as a ‘settings’ approach [ 8 ] and in North America as coordinated school health programmes, provides a framework for those approaches which incorporate a formal health curriculum; promotion of a healthy school environment and ethos that can benefit pupils, teachers, and non-teaching staff alike; and engagement with families and communities [ 9 ].

Recent reviews have identified evidence about the contribution that comprehensive, integrated approaches to health promotion in schools can make to improving children’s and young people’s health in a number of areas [ 9 , 10 ]. Understanding of how these effects are attained is increasing [ 11 ]. However, understanding of how the constituents of such programmes can be best implemented in schools remains a neglected area [ 12 ].

The reality of implementing health promotion programmes in schools involves the active engagement of a range of actors [ 13 , 14 ] and the adaptation of programmes to local contexts [ 15 , 16 ] within a wider educational and public health system. They can thus be considered as complex interventions (multi-component, context-sensitive, and highly dependent on the behaviours of participants and providers) within a complex system [ 17 ].

Our aim was to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools (see Table  1 for definitions) taking full account of these complexities. Our research questions were as follows:

• What are the main factors or mechanisms that are thought to explain the success or failure of the implementation of health promotion programmes in schools?
• Is there an association between these factors and mechanisms and the successful implementation of health promotion programmes in schools?
• For what public health problems and in what circumstances do schools provide a feasible and sustainable setting for health promotion in the United Kingdom?

Definition of terms used in the review

We chose to conduct a realist review in order to attain a contextualised understanding of how and why complex interventions achieve particular effects—in realist terminology (see Table  1 ), how mechanisms lead to outcomes in particular contexts [ 18 , 19 ]. The realist approach involves testing ‘programme theories’—often expressed as a model linking outcomes to programme activities and the underlying theoretical assumptions [ 20 ]. This approach has commonalities with other approaches such as Intervention Mapping [ 14 ] and Medical Research Council guidance on process evaluation of complex interventions [ 21 ], but differs by being explicitly situated in a realist philosophy of science [ 22 , 23 ]. A realist philosophy of science posits that the identification and testing of contextualised, generative mechanisms provide the greatest explanatory potential for phenomena and the strongest basis for inferring how mechanisms will operate in other contexts [ 23 ]. It differs from an ‘idealist’ philosophy that endeavours to establish causation by ruling out alternative atheoretical patterns.

Contained within programme theories, even if not explicitly stated, are ideas about how a problem can best be addressed and how factors that may undermine the actions of the programme can themselves be addressed [ 24 ]. Realist review methods have been specifically advocated for evaluating evidence about complex interventions and their implementation [ 19 , 25 ]. For this topic, three factors led us to choose realist review over a mediator and moderator analysis. First, the measures (or ‘markers’) of implementation are not well-developed or standardised. Second, we envisaged that the diversity of trial methodology and complexity of the relationships between phenomena would be likely to preclude use of meta-regression of multivariate studies. Third, the diversity of qualitative and quantitative research evidence required a coherent approach for synthesis.

The review was conducted in two phases. First, ideas about what enables or inhibits the implementation of health promotion programmes in schools (programme theories) were identified from a range of published and other sources. Second, these programme theories were tested (challenged, endorsed, and/or refined) using evidence from evaluations of United Kingdom (UK) school health promotion programmes. We endeavoured to identify mechanisms (how a programme’s resources or opportunities interact with the reasoning of individuals and lead to changes in behaviour) and contexts (the wider configuration of factors, not necessarily connected to a programme, that may enable or constrain the operation of specific mechanisms) so that context-mechanism-outcome configurations could be specified. The identified evidence meant that this was possible to a much greater extent in relation to earlier (preparation and initial implementation) rather than later (embedding and evolution) stages of implementation. Our focus on implementation therefore includes intervention delivery characteristics that are often evaluated in conventional effectiveness studies [ 26 ] but extends this focus to include levels of complexity about those delivering a programme and the system in which they practise.

The full protocol for the review has previously been published [ 27 ]. The review is reported in accordance with the RAMESES publication standards [ 28 ].

Search strategy

Our approach to searching was iterative, consisting of sensitising, wide-ranging, and supplementary searches. This enabled us to map and explore a wide range of conceptual sources relating to the implementation of health programmes (both in schools and other settings), whilst also locating empirical studies conducted in the UK for programme theory testing.

Screening (theory-development stage)

The first stage of the review was designed to both identify and develop programme theories and to ‘map the terrain’ of the implementation of health promotion programmes in schools in Organisation for Economic Co-operation and Development (OECD) countries. Sources that provided rich descriptions of the delivery of school-based health promotion for children aged 5–16 years in any OECD country were included. These included editorials, opinion pieces, commentaries, comparative effectiveness studies, process evaluations, qualitative research, and systematic reviews.

Titles and abstracts were read by the reviewers (MP, RC) to identify key ‘implementation’ terms and synonyms that could inform the development with the information specialist (HW) of the ‘sensitising’ search strategy. Key documents relating to the implementation of health programmes in schools were also identified and used to search for other documents which had cited them. We deliberately used a wide definition of ‘key’—for example, sources could be considered ‘key’ because they were a candid reflection on the implementation of a health promotion programme or because they were strongly conceptualised (i.e. a strongly theoretically informed inquiry). This stage was also used to ‘sensitise’ us as researchers to the emerging field of implementation science (as it related to health promotion in schools) and to potential programme theories.

However, we did not intend for the sensitising stage to be exhaustive—the aim was to locate a reasonable range of terms and sources that could inform further searches and deepen our understanding of the field (see Additional file 1 for record of (and reasons for) the sources obtained).

To help focus our identification and development of programme theories, we kept in mind examples of theories that struck a balance between being broad enough to identify a potentially significant relationship and specific enough to be testable (i.e. middle-range theories, the most useful theories on which we would focus in our development of bespoke programme theories). These middle-range theories can be thought of as lying between localised and non-theoretical individual examples or instances and broad, generic theories, both of which would be harder to test using information about particular programmes.

Screening (theory-testing stage)

For inclusion in the second stage of the review, studies had to be linked to an empirical evaluation of a primary- or secondary-school-based health promotion programme in the UK (i.e. schools for children aged 5–16 years). For example, a process evaluation that documented implementation processes alongside a trial was considered to be ‘linked’. We included evaluations that used a range of comparative study designs—RCTs, controlled before and after studies, and before and after studies. Detailed inclusion criteria are described in the protocol [ 27 ].

Screening was conducted by two reviewers (MP, RC) using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education) to manage references and record coding decisions.

We ‘mapped’ sources for both theory-development and theory-testing stages in two main ways. We first used the abstract to assess the likely clarity, richness, and extent of conceptualisation of programme theories that a source could potentially provide. This assessment used criteria proposed by Ritzer [ 29 ] and Roen et al. [ 30 ] (Table  2 ). We then categorised sources by ‘type’—policy document, editorial, opinion piece or letter, commentary, reflection on practice, comparative effectiveness study, evaluation and/or process evaluation, qualitative research, survey, systematic review, narrative review, or conceptual review. This enabled us to use a sampling strategy which focused on those sources that would potentially contribute the most to the development of a conceptual framework (i.e. those that were ‘conceptually rich’). It also enabled us to purposively sample ‘less conceptually rich’ sources such as policy documents or editorials that could nevertheless contain important contributions for the development of a conceptual framework. This strategy was informed by the idea of ‘theoretical saturation’, where data collections stops at the point at which collection of further data is considered unlikely to yield further insights [ 31 ]. The flow of studies through the review is shown in Fig.  1 .

Criteria used for assessing the conceptual richness of sources

Flowchart of sources through the review

Development of programme theories

We recognised from the outset that building a conceptual framework for the implementation of health promotion programmes in schools would be a process that initially focused on discussion and debate within the research team. Both reviewers (MP and RC) read, annotated, and took notes from all of the sources categorised as conceptually rich ( n  = 19) with a view to producing a coherent framework that encompassed all of the implementation aspects identified in the sources. We pursued citations from these sources where we judged that they held potential to contribute substantively to the conceptual framework and, as a result, included two further sources. One was directly related to health promotion in schools [ 32 ] whilst one was not specific to health promotion but related to change at the level of the school [ 33 ]. One further source categorised as ‘thick’ was included [ 15 ] as it was closely linked with another conceptually rich source [ 34 ]. A total of 22 sources informed the development of the conceptual framework and theory-development review phase (Additional file 2 ).

Amongst these, a narrative review by Samdal and Rowling [ 5 ] presented a list of eight ‘rationales for implementation components’ that were presented in a form similar to programme theories. We took the decision to use these theories as our starting point from which to explore how the programme theories in the other 21 conceptually rich sources could expand or refine these theories. This enabled us to develop a ‘long list’ of 12 programme theories (Additional file 3 ) that encompassed all of the concepts around implementation identified in the 22 conceptually rich sources (including the Samdal and Rowling narrative review [ 5 ]) and to identify the unique contributions of each source. These programme theories were developed and prioritised further on the basis of discussions in our first review advisory group meeting with educational and health professionals and health researchers (see Additional file 4 for further details).

The final expression of four programme theories encompassed the processes of preparing for, introducing, embedding, and adapting health promotion programmes in schools. These were discussed and agreed via email correspondence with the advisory group’s members. The three stages of programme theory development, showing the areas in which different sources contributed, are documented in Additional file 5 .

Testing of programme theories

To help guide our efforts in the extraction and synthesis of relevant evidence from included studies in the second (theory-testing) stage of the review, we summarised the programme theories in a conceptual framework (Fig.  2 ). Phase 2 of the review included evaluations of health promotion programmes delivered in UK primary or secondary schools that reported findings that enabled aspects of the four programme theories to be tested. Table  3 lists the details of the 41 included papers, reporting evaluations of 20 different health promotion programmes in schools—11 of which were delivered in primary schools and 9 in secondary schools. A brief summary of each programme is provided in the table, with full details reported in Additional file 6 .

Characteristics of included empirical UK studies and the programme theories (PT) for which they provided evidence

BA before and after study, CBA controlled before and after study, CRCT cluster randomised controlled trial, NRCT non-randomised controlled trial, SRE sex and relationship education, SES socio-economic status, NC non-comparative, NR not reported, NA not applicable

Conceptual framework for designing and implementing health promotion programmes in schools

Critical appraisal

All included studies were critically appraised using the Wallace et al. [ 35 ] tool for assessing quantitative, qualitative, and mixed-methods studies. This enabled the strengths and weaknesses of different aspects of each study to be identified, rather than a summary verdict on the quality of the whole study. A summary of the key points of the critical appraisal was included in each data extraction table and collated in a summary critical appraisal table (see Additional file 7 ).

Data extraction

Information on study type, the programme being evaluated, the content and delivery of the programme, and research methods (sample, participants, data collection and analysis) and evidence to enable testing of each of the four programme theories were extracted to data extraction tables (Additional file 8 ). To facilitate synthesis, where evaluation of a health promotion programme was reported across multiple publications, all data was extracted to a single table.

As evidence to test the programme theories was rarely reported in a consistent format or section within papers, we used contents pages, the executive summary, sub-headings, and/or the conclusions (as appropriate to the publication type) in order to ‘gain a foothold’ and start the process of reading and data extraction. This was an iterative process which involved our critical consideration of the extent to which studies’ findings enabled the programme theories to be tested. Our decision-making was guided by looking for ‘markers of implementation’ (for example, stakeholders’ experiences, perceptions, and competencies—see Additional file 9 ), although we did not limit extracted data to only these ‘markers’ if we judged other evidence to be relevant. For example, relevant evidence could be indirect, such as the effect of homophobic attitudes (on the part of both teachers and pupils) on levels of engagement in sex and relationship education (SRE).

The volume of reported information in some studies and our desire to not lose the potential contribution of authors’ analyses to the synthesis meant that we judged when it was necessary to either summarise data or extract authors’ analyses. Here we used the distinction made in meta-ethnography between first- and second-order interpretations [ 36 ]. In recording data, we used double quotes where study participants’ views, experiences, or understandings were reported in their own words (first-order interpretation) and single quotes where study authors’ analyses were extracted (second-order interpretations). As our aim was to identify and extract key pieces of information, we recorded additional contextual information or critical appraisal findings immediately adjacent to the relevant extracted data. This guarded against our synthesis being conducted without knowledge of these factors, which might relate to a particular piece of evidence but not the study as a whole. To attain consistency, each critical appraisal and data extraction was checked by the lead reviewer (MP), with feedback or revisions provided as appropriate.

Consistent with a realist approach to the explanation of complex phenomena, where relationships between phenomena may be multi-factorial, inter-dependent, and emergent, we treated the ‘ways of synthesising’ as principles to critically apply rather than strict instructions to use on each piece of evidence. The iterative and explanatory nature of synthesis in a realist review meant that the processes of juxtaposition, reconciliation, consolidation, situation, and adjudication of different sources and evidence [ 18 ] (see Table  1 ) were used in combination rather than separately. Whilst we had conducted critical appraisal before the synthesis (rather than concurrently, as advocated by Pawson [ 37 , 38 ], in adjudicating between different sources, we were careful to use the findings of the critical appraisal in relation to the relevant aspects of or insights from a study rather than judging the validity of each study as a whole. If our initial critical appraisal was unable to support a judgement about a particular piece of evidence, we returned to the original source so that a bespoke appraisal incorporating rigour and relevance could be made. We believe that this is a more transparent process for incorporating rigour and relevance in the conduct of a realist synthesis than solely appraising studies during synthesis.

Throughout the synthesis, we bore in mind the implications of emerging explanations for testing each of the programme theories. Details of the practical stages of the synthesis can be found in Additional file 10 .

We present our findings as a summary of contextualised mechanisms relating to each of the issues encountered in each programme theory, noting the depth, breadth, and overall rigour of the underlying evidence. The summaries are intended to facilitate decision-makers’ and practitioners’ sensemaking of local contexts, thereby facilitating self-organisation at the local level [ 39 ].

To enhance the readability of the summaries within a limited space, citations to the evidence underpinning each programme theory are contained in Table  4 (rather than in the text) together with a summary of context-mechanism-outcome configurations. Additional file 11 contains a longer version of the findings (see Table  4 for page numbers relating to each context-mechanism-outcome configuration), with examples and greater detail about the rigour of individual pieces of evidence used in the synthesis.

Programme theories tested in the review

Key (type of health promotion programme): Alc alcohol, Drug legal and illegal drugs, Ob obesity, PA physical activity, SRE sex and relationship education, Tob tobacco, WB well-being

a For full synthesis, see Additional file 11

Programme theory 1: preparing for implementation

Pre-delivery consultation.

Whilst the rigour of the underlying evidence is highly variable, both the type of health promotion programme and the recent school history of delivering programmes on the topic are likely to impact on the extent and depth of pre-delivery consultation needed. A more ‘mature’ and uncontentious area of health promotion such as physical activity, where there is a history of delivering similar programmes and existing staff and organisational networks provide a foundation to support programme delivery, is likely to require substantive but brief ‘pre-delivery’ consultation with school staff and parents. Where aspects of health promotion are less well-established, such as social and emotional issues in SRE, and where the topic may be a highly charged personal issue for teachers (for example, in terms of morality and sexual identity), more extensive ‘pre-delivery’ consultation with school staff and parents is likely to be necessary. Areas of health promotion such as healthy eating and smoking prevention, whilst relatively uncontentious, may still require significant pre-delivery consultation, especially where a programme contains novel components of delivery or content with which school staff are unfamiliar.

Pupil engagement

Making a health promotion programme appealing to pupils is not necessarily straightforward. Programmes need to be developmentally appropriate and address issues perceived as relevant by pupils, whilst at the same time stretching pupils’ understanding of health issues that may lie well outside of their experience or understanding. ‘Sweeteners’ can play an important role—pupils are strategic thinkers themselves and may well respond to the ‘multiple pay-offs’ that a programme can offer such as the development of transferable educational or life skills. None of these more complex considerations should pressurise programme designers and school staff into overlooking the potential of a simple ‘hook’, such as the novelty of an external provider, for engaging pupils’ attention.

Reciprocity

Preparing for the delivery of a health promotion programme in a school revolves around reciprocity. On the whole, teachers will devote their time and energy if they believe that they will get the practical and educational support to enable them to play their role. Even if this reciprocity is more symbolic than practical at the initial stages, it can start a process of engagement that fosters co-operation towards achieving a common goal, such as improved health outcomes for pupils through delivery of a health promotion programme.

Reciprocity is also important for pupils. Long-term health gains are mostly an abstract concept for pupils of both primary and secondary school age, so they need to perceive other, more short-term (and non-health) gains from participating in a health promotion programme. Amongst other things, this can be related simply to enjoyment (having some fun), identity development (e.g. status amongst peers), or mid-term goals (e.g. developing transferable skills).

Both teachers and secondary-school-age pupils try to ensure that actions contribute to more than one beneficial outcome. This does not override the contribution of intrinsic motivation, such as teachers’ desire to play a pastoral role in child development or pupils’ appreciation of knowledge about a healthy lifestyle. However, it does highlight that the delivery of a health promotion programme in a school has to take place within current frameworks that demand outcomes on many levels. Teachers will want to balance pupils’ educational goals and psycho-social development with the demands of the local and school political environment, their personal work/life balance, and career development. Pupils will want to achieve their educational goals and develop psycho-socially (albeit this may simply be perceived as ‘growing up’). The extent to which the preparation for delivery of a programme considers how these diverse goals can be accomplished is central to successful implementation.

Negotiation (about SRE programme delivery)

There is evidence from a well-conducted process evaluation of a SRE programme (the SHARE programme—Sexual Health and Relationships: Safe, Happy and Responsible) that negotiation about, and adaptation of, health promotion programmes in schools takes place in a wider context than ‘health’. At the school level, decisions about programme content and delivery are political in the sense that they aim to balance the views and demands of a broad range of stakeholders. The extent to which this applies in areas of health promotion other than SRE is unclear.

Concordance of the programme with current practice and interests

There is weaker, observational evidence from a range of health promotion programmes that concordance between a programme and current school activities and priorities works in a number of different ways:

• Meeting an unmet need in a school in a way that is consistent with other school activities (i.e. ‘meshing’)
• ‘Working with’ and therefore contributing to the development of a particular school ethos (i.e. ‘complementing’)
• Co-ordinating other school activities to fit with programme components (i.e. ‘driving’)

Sometimes, even where there appears to be a lack of concordance between a programme and some school activities, this can act as a stimulus for change and mutual accommodation. However, this may require early recognition and careful negotiation.

Programme theory 2: introducing a programme within a school

Integrating a programme into the life of a school.

Active support by senior figures within a school is necessary but has to extend deeper than written policies—the ways in which policies will be put into action ‘on the ground’ need to be specific and clear. This is because the organisation and delivery of health promotion programmes can be experienced by teachers as an additional responsibility, and one which they are unlikely to want to ‘go the extra mile for’ if doing so is perceived as risky for their professional life, personal well-being, or work-life balance. The pathway of programme introduction and delivery needs to be both paved (practical assistance—specific training, resources, and co-ordination with other aspects of school life) and sheltered (from local or national outside parties who disagree with a programme’s focus or approach).

The importance of this ‘on the ground’ support broadly follows a continuum, with support being less pivotal at the primary school level where a teacher’s class usually consists of the same group of pupils and less contentious health promotion topics are addressed. At the secondary school level, where pupils’ subject options can lead to more change in class composition, there may be pronounced differences in levels of maturity, and as more contentious health promotion topics are addressed, this support becomes more important. The need for and specific type of support and training will also critically depend on whether the people delivering the programme are teachers or other professionals working within a school. For example, teachers may need skills and confidence in specific behaviour change techniques that are part of the programme, whereas outside professionals delivering the programme may need skills and confidence in classroom management.

Whether programmes are delivered by teachers, external professionals, peer educators, or a mixture of these, in both primary and secondary schools, it was consistently reported that a named co-ordinator was important for initiating and sustaining programme delivery. The profession or status of this person, and whether or not he/she was a school employee, was far less important than his/her willingness to co-ordinate, his/her skills and capacity to do so, and his/her ability to exert influence within the school.

Engaging those who deliver and participate in health promotion programmes

Across both primary and secondary school levels and a range of health promotion topics, the motivation of those delivering programmes to engage in training depended on whether or not the training addressed knowledge or skill deficits that were relevant from their point of view. This links with reciprocity (see programme theory 1 summary)—both teachers and pupils are more likely to engage when they can see the likely personal, social, and/or developmental gains from participating. Engagement can be problematic where there is discordance between health promotion topics and personal values, although this is only reported in relation to SRE.

The engagement of pupils as participants broadly follows a continuum in line with psycho-social development. At the primary school age, the key issue is whether or not a programme is fun. As pupils progress through the secondary school years and health promotion addresses more contentious issues such as sexual relationships and substance use, fun remains necessary but is not sufficient. Addressing a perceived skill or knowledge deficit and the quality of the relationship between participants and those delivering the programme assume a greater importance. Participants’ confidence in the maintenance of confidentiality can be highly important for engagement in topics such as SRE and substance use.

In both primary and secondary schools and for a range of health promotion topics and programme types, engagement was facilitated by programmes being sufficiently flexible to allow tailoring to different levels of pupils’ physical, psychological, and social development and different levels of skill and experience (both of pupils and those who are delivering a programme).

Programme theory 3: embedding a programme into routine practice

The research timeframes of included studies were mostly too short (2 years or less) to produce evidence about the embedding of health promotion programmes. There is limited evidence in the short term about the impact of co-ordination of programmes with other school activities, but this does not add substantively to that identified in the programme theory 2 summary. Other evidence about embedding is limited to the views of teachers and managers about aspects they think would help, such as senior support and networking. However, the fact that teachers and managers had to venture ideas about how to embed programmes strongly suggests that considerations of sustainability were simply not part of any of the design of programmes.

Programme theory 4: fidelity of implementation and programme adaptation

There was substantial variation across all programmes in how they were delivered in different schools, but in the included studies, it was not possible to distinguish ‘warranted variation’ (for example, based on informed professional judgement) from ‘unwarranted variation’ driven by other factors. The usefulness and acceptability of programmes where core and customisable elements were specified was not evaluated, although there was considerable ambivalence expressed by teachers about the usefulness of more prescriptive programmes. An evaluation of a SRE programme suggests that fidelity of implementation is enabled when teachers work within a collegial atmosphere where issues about programme delivery can be openly discussed with colleagues and support obtained from senior staff in the school and the programme’s developers.

This is the first review of the implementation of health promotion programmes in schools to have been conducted using a recognised review method. The use of realist review was novel in this field, and through its application, we have been able to improve understanding of transferable mechanisms rather than simply identifying de-contextualised implementation processes. Our review has consolidated and refined existing conceptual frameworks and used evaluations in UK schools of a range of health promotion topic areas to specify key context-mechanism-outcome configurations. These configurations are presented in a narrative designed to facilitate decision-makers’ and practitioners’ use of the findings in conjunction with knowledge of their local contexts. In this way, we have extended the work of Greenberg et al. [ 32 ] and Samdal and Rowling [ 5 ] by moving beyond statements about the principles of good implementation practice and towards a more refined understanding of the complexity of implementation within educational, public health, and social systems that are constrained in multiple, setting-specific ways.

Our findings have identified key transferable mechanisms (e.g. reciprocity) that impact on implementation and which apply to both teachers and pupils. We have also been able to specify how an accepted principle of implementation, such as congruence between existing school activities and proposed health promotion activities, can operate differently (but beneficially) according to context—for example, by meeting unmet needs, complementing existing activities, or paradoxically by stimulating change so that congruence is achieved. Our findings have also identified where some of the mechanisms that underpin implementation differ in how they operate between primary and secondary schools and between health promotion topics. By exploring context-mechanism-outcome configurations, we have also been able to go beyond generic ‘one recommendation fits all’ statements. For example, we have been able to specify the actions that senior school figures should take in order to provide support for the implementation of a health promotion programme.

Whilst our synthesis provides greater specificity in relation to preparing for implementation and initial implementation of health promotion programmes in schools, the amount, depth, and rigour of evidence about the later stage of embedding into routine practice and the cross-cutting theme of adaptation and evolution (Fig.  2 ) were limited. This meant that we were unable to explore important areas identified in our programme theory relating to embedding into routine practice. For example, we were unable to locate evidence about how different stakeholders’ goals are reconciled; how stakeholders’ enthusiasm, knowledge, and experience are harnessed; and how knowledge about core and customisable elements of programmes are retained in the longer term. An explanation for this is that the timeframe over which evaluations are funded simply do not extend sufficiently far to investigate these factors. Nevertheless, some of the key mechanisms and contexts identified as relevant to the initial implementation of programmes may also be important for longer term embedding or ‘scaling up’ from school to school.

Regarding adaptation and evolution, the planned content and delivery of a number of the programmes evaluated were under-specified, meaning that assessment of fidelity and judging the extent to which (or justification for) adaptation of programmes took place was highly problematic. Tailoring of programmes to meet the needs of participants, both those who deliver a programme (for example, addressing specific skill deficits) and the pupils who are its intended beneficiaries (for example, tailoring to different levels of physical, psychological, and social development), whilst preserving the essential functional components of the programme, is a central challenge which we have not been able to address using the evidence located for this review.

Our findings provide a platform for future evaluations of implementation processes in schools. For example, whilst we have identified the impact of a wide range of stakeholders about the content and delivery of a SRE programme, we were unable to locate evidence about this for other types of health promotion programmes. SRE programmes may represent a distinct, and in some communities particularly contentious, area of health promotion. However, in the absence of research about how stakeholders impact on the implementation of other types of health promotion programmes, we do not know if the mechanisms in operation are the same or different.

Whilst we could, as the review’s authors, speculate about more specific recommendations for public health programme designers, promoters, deliverers, and evaluators, we believe we are not best placed to do this—especially as what may be a salient and useful insight for one group of potential research users (such as head teachers or school governors) may be seen as irrelevant or obvious to another group (such as programme developers and promoters). For this reason, we have undertaken another consultation exercise with representatives of these different groups, which will lead to tailored evidence summaries and recommendations for these different key groups, including commissioners and funders of public health programmes.

Strengths and limitations

This realist review has drawn on a range of types of evidence about implementing health promotion programmes in schools to produce new insights that are relevant to a range of decision-makers. Using a realist approach has provided a consistent logic of inquiry for synthesising evidence across different types of programmes. Through our provision of extensive review process documentation, we hope to enable other reviewers to judiciously apply a realist approach, as well as provide substantive material for critiques that will foster methodological development.

Whilst we have been able to identify context-mechanism-outcome configurations (such as reciprocity) in depth for certain aspects of implementation, this was not the case for all aspects. These differences reflect the extent and depth of the underlying evidence but also, quite simply, the difficulty of identifying ‘hidden’ mechanisms. For those embarking on realist reviews now, it is worth contemplating that we could have widened our searches to other fields, included evaluations from outside of the UK, and/or drawn more closely on our review advisory group’s knowledge to help identify context-mechanism-outcome configurations in these more ‘difficult’ areas.

The notable lack of evidence about what determines the longer term sustainability of programmes (i.e. their embedding in schools year on year), or their ‘spread’ from school to school, may require comparative primary research, for example, comparing effective programmes which have become widespread within some countries (like the ASSIST programme in Wales and England; see University of Bristol’s REF 2014 impact statement [ 40 ] for a description of the impressive uptake of this programme) with others which, whilst found to be effective, never became widely adopted. This may reveal further how different schools or different school systems either complement or conflict with the practicalities of delivering particular programmes. Such research may also reveal whether longer term implementation may rely on stable organisational and budgetary boundaries, together with more compelling evidence of cost-effectiveness—or other factors which would probably not be revealed by initial evaluations in relatively few schools, when subsidised by evaluation funding and often also energised by the original developers of the programme.

Through applying a realist approach, we have been able to identify mechanisms in action that affect the successful implementation of health promotion programmes in schools. At the preparatory stage, implementation hinges on negotiation about programme delivery and the acceptability (or otherwise) of the programme to those who will deliver it. Addressing fears about programme novelty, contentious subject matter, and the extent of support for delivery are likely to be important. At the initial implementation stage, programme delivery needs to be both facilitated within a school and protected from external forces. This becomes more important where the composition of groups of pupils is more complex and where more contentious health issues are addressed. The available evidence was insufficient for us to confidently identify mechanisms about the process of embedding programmes into practice or the circumstances where the adaptation and evolution of programmes is necessary for them to be feasible and sustainable.

Our inclusion of a diversity of sources of information and integration of a review advisory group’s input throughout the review have enabled us to produce findings that are both academically rigorous and applicable to decision-making at a range of local and strategic levels. Further research should focus more on investigating and refining the identified mechanisms (both in trials of interventions and evaluations of local practice), the dynamic nature of programme adaptation during implementation, and programme sustainability.

Availability of supporting data

The data sets supporting the results of this article are included within the article and its additional files.

Acknowledgements

This project was funded by the NIHR School for Public Health Research (SPHR). The NIHR SPHR is a partnership between the Universities of Sheffield, Bristol, Cambridge, and UCL; The London School for Hygiene and Tropical Medicine; The University of Exeter Medical School; the LiLaC collaboration between the Universities of Liverpool and Lancaster and ‘Fuse’; and The Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland, and Teesside Universities.

The NIHR SPHR commissioned the research following peer review but, otherwise, had no involvement in the design or analysis of the research. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

Thanks are due to our review advisory group for their input and critique throughout the review and to Rebecca Abbott (NIHR CLAHRC South West Peninsula) for valuable feedback on the presentation of this paper. The incisive feedback from the two peer reviewers of this paper helped to significantly improve its methodological clarity and presentation.

Additional files

Search strategy. The file is a record of (and reasons for) the sources obtained. (DOCX 20 kb)

Contribution of conceptually rich studies. A total of 22 sources informed the development of the conceptual framework and theory-development review phase. (DOCX 30 kb)

Long list of programme theories. The file contains a list of 12 programme theories that encompassed all of the concepts around implementation identified in the 22 conceptually rich sources and to identify the unique contributions of each source. (DOCX 17 kb)

review advisory group. The RAG was formed to contribute to the identification, selection, and refinement of programme theories to be tested in the review. (DOCX 24 kb)

Contribution of sources to development of programme theories. The file is a documentation of the three stages of programme theory development, showing the areas in which different sources contributed. (DOCX 23 kb)

Programme descriptions. The file reports the full details of each programme. (DOCX 26 kb)

Critical appraisal summary. A summary of the key points of the critical appraisal collated in a summary critical appraisal table. (DOCX 21 kb)

Data extraction tables. The file lists information on study type, the programme being evaluated, the content and delivery of the programme, and research methods (sample, participants, data collection and analysis) and evidence to enable testing of each of the four programme theories. (DOCX 24 kb)

Markers of implementation. Our decision-making was guided by looking for ‘markers of implementation’, although we did not limit extracted data to only these ‘markers’ if we judged other evidence to be relevant. (DOCX 19 kb)

Practical stages of the synthesis. The file lists the details of the practical stages of the synthesis. (DOCX 17 kb)

Long version of synthesis. The file contains a long version of the findings, with examples and greater detail about the rigour of individual pieces of evidence used in the synthesis. (DOCX 84 kb)

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MP wrote the first and subsequent drafts of this manuscript, with comments from RC and RA, and then the remaining authors. RA, KW, TF, and CA conceptualised the study. MP, RA, KW, TF, and CA designed the study. MP, RC, and RA conducted data analysis and interpretation, with additional input to data interpretation by KW, TF, and CA. HW designed and conducted the database searches. All authors read and approved the final manuscript.

Contributor Information

M. Pearson, Phone: 0044 1392 726079, Email: [email protected] .

R. Chilton, Email: moc.liamtoh@82notlihcyor .

K. Wyatt, Email: [email protected] .

C. Abraham, Email: [email protected] .

T. Ford, Email: [email protected] .

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R. Anderson, Email: [email protected] .

USC Leonard Davis Faculty Member Receives 2024 Vincent Cristofalo Rising Star in Aging Research Award

Home » USC Leonard Davis Faculty Member Receives 2024 Vincent Cristofalo Rising Star in Aging Research Award

The American Federation for Aging Research recognized Associate Professor Bérénice Benayoun for her exemplary research contributions.

USC Leonard Davis School of Gerontology Associate Professor Bérénice Benayoun has received the 2024 Vincent Cristofalo Rising Star in Aging Research Award from the American Federation for Aging Research (AFAR), a national non-profit organization whose mission is to support and advance healthy aging through biomedical research .

Benayoun, who also has appointments in biological sciences, biochemistry and molecular medicine at USC, focuses her research on big data , sex differences , and immune function in relation to aging. Her lab’s overarching goal is to understand how genomic regulation mechanisms influence aging, health, and chronic disease , and how these mechanisms are modulated in response to environmental stimuli and in the context of specific endogenous factors, such as biological sex, in vertebrate model organisms. The Benayoun lab is also one of the pioneering labs in the development of a naturally short-lived vertebrate as a new model for aging research, the African turquoise killifish  Nothobranchius furzeri .

“This award is a validation of my choice to substantially shift from my postdoctoral research topics and embrace research of sex differences. It’s so humbling to be an awardee, now among a long list of people I look up to in the field,” she said. “I am tremendously grateful to all my trainees so far, without whom I would not be in a position to receive this amazing award. Working with them has been a pleasure, and I want to dedicate this honor to them as well!”

Benayoun has authored 71 peer-reviewed publications (43 as first and/or corresponding author), and her overall body of work has been cited more than 5600 times. Leveraging her 2020 Glenn Foundation for Medical Research and AFAR Grants for Junior Faculty, she has secured a total of $7.58M in direct costs ($10.7M in total costs) across 16 grants, 14 as principal investigator/co-principal investigator, including an R35 Maximizing Investigators’ Research Award from the National Institute of General Medical Sciences and a prestigious K99/R00 Pathway to Independence grant from the National Institute on Aging.

Benayoun also has been recognized with numerous awards for her research, including the Nathan Shock New Investigator Award from the Gerontological Society of America, Rising Star in Reproductive Biology Award from the Society for the Study of Reproduction, Rosalind Franklin Young Investigator Award in Mammalian Genetics, Pew Biomedical Scholar Award , and Junior Scholar Award from the Global Consortium for Reproductive Longevity and Equality.

“Bérénice is not only a brilliant, creative, and innovative scientist but is also dedicated to creating and sharing new data resources with colleagues across the world to advance the geroscience field as a whole,” said Pinchas Cohen , dean of the USC Leonard Davis School. “This award is richly deserved; she is truly a rising star who will continue to shine.”

Benayoun is the third USC Leonard Davis faculty member to receive the prestigious Cristofalo award. Colleagues Valter Longo and Sean Curran received the award in 2013 and 2020, respectively.

The award is named in honor of the late Vincent Cristofalo , who dedicated his career to aging research and encouraged young scientists to investigate important issues in the biology of aging. Established in 2008, the award is a framed citation and carries a cash prize of $5,000. Benayoun will receive the Cristofalo Award at the American Aging Association Annual Meeting on June 2 in Madison WI, where she will present a lecture on her research titled “Sex-dimorphic regulation of macrophage aging in mice.”

“Dr. Benayoun’s impact on the field of aging research and scientific community is far reaching, she has become a trusted collaborator to many and developed innovative new resources and data sets that she shares freely with the geroscience community,” said Stephanie Lederman, Executive Director of AFAR. “She carries on the visionary commitment of this award’s namesake by advancing research that will help us all live healthier, longer.”

Release courtesy of the American Federation for Aging Research. Additional reporting by Beth Newcomb.

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