What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach?

Summary

The issue

School health promotion, based on a wide range of research and practice, has evolved over the course of the last 50 years, alongside health promotion in other settings. During the 1990s, WHO, working jointly with the European Commission and the Council of Europe, developed the health promoting schools initiative. It is a multifactorial approach that covers teaching health knowledge and skills in the classroom, changing the social and physical environment of the school, and creating links with the wider community. This synthesis seeks to determine the effectiveness of health promotion in schools and, more specifically, the effectiveness of the “health promoting schools” approach. The synthesis builds on the last comprehensive review in this field, published in 1997.

Findings

This synthesis identified good quality systematic reviews that covered mental health, aggressive behaviour, healthy eating, physical activity, substance use and misuse, driver education, and peer approaches.

Reviews of programmes that promoted mental health in schools (including preventing violence and aggression) show these programmes to be among the most effective ones in promoting health. Of these programmes, the ones that were most effective were of long duration and high intensity, and involved the whole school. New reviews that focused on promoting healthy eating and physical activity confirmed an earlier review, which found that multifactorial interventions, particularly those involving changes to the school environment, were effective. Four new reviews of programmes that focused on promoting the prevention of substance use confirmed previous findings that these programmes are relatively ineffective. Also, programmes on preventing suicide reduced suicide potential, depression, stress and anger, but less rigorous studies suggested a potential harmful effect in young males. In some (but not all) studies, peer-delivered health promotion was found to be effective, compared with teacher-led interventions, and this approach was highly valued by the young people involved.

The systematic review, which evaluated health outcomes of programmes that used elements of the health promoting schools approach, included small studies of variable quality. It found apparent benefits to the social and physical environment of the school, and some studies found the programmes benefited health-related behaviour (dietary intake and physical fitness). No reviews evaluated the cost–effectiveness of the programmes or interventions.

Policy considerations

Health promotion in schools can improve children’s health and well-being. Among the most effective programmes are those that promote mental health, healthy eating and physical activity. Programmes on preventing substance abuse have not been shown to be effective and may be better addressed in a more holistic programme that promotes mental health. Programmes on preventing suicide can reduce suicide potential, but potential harmful effects in young males should be considered. Although programmes based on peer-delivered health promotion are highly valued by young people, their effectiveness varies.

Some evidence supports key components of the health promoting schools programme – namely, that programmes should be sustained, multifactorial, whole school approaches that provide appropriate training. However, there is a lack of evidence on all the elements that contribute to an effective health promotion programme, or to the health promoting schools approach as a whole. A holistic evaluation of programmes in local settings is needed.

Type of evidence

This review is based on robust systematic reviews of controlled trials of school-based health promotion initiatives. Reviews on school health services and screening programmes were not included.