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Project Title: The effects of schools and school-environment interventions on health: evidence mapping and syntheses

Start date:	1 June 2010
Reference number:	09/3002/08
Lead:	Dr Christopher Bonell
Institution:	Senior Lecturer Social Science and Epidemiology London School of Hygiene and Tropical Medicine
Status:	Research in progress
Plain English summary:	Schools can significantly affect the mental and physical health of students and staff (and perhaps parents and the local community). Some projects, called 'school-environment' projects try to change the way schools are run to promote health. They do so by a variety of methods which go beyond just telling students what is healthy and what isn't. They might involve: working with staff and students to change school policies for example on bullying or smoking; providing staff with training on how to re-engage students who don't like school; improving catering; encouraging staff and students to walk or cycle to school; and encouraging students to take on new responsibilities such as becoming 'mediators' to combat bullying. Some research studies suggest these 'school-environment' projects can bring benefits for students such as reduced violence and drug use, increased physical activity and healthy eating. Some research also suggests that, even in the absence of these 'school-environment' projects, some schools simply have healthier students than others. These differences can't be explained away simply because the schools admit different sorts of students or are in different sorts of neighbourhoods. The differences seem to reflect how the schools are run and the quality of relationships between students and staff. But we also know that the picture is complicated: some projects that try to make schools healthier places don't work. And some health issues, like obesity, don't always seem to vary much between schools. To decide what sorts of actions schools in the UK should take to improve health, we need to be clear about what existing research tells us. We need information on the benefits (and perhaps the harms) that specific 'school-environment' projects have brought about, how these projects were carried out, whether they were acceptable to students and staff, and how much they cost. We also want to know what it is about some schools that make them healthier than other schools even in the absence of a specific 'school-environment' project. This isn't an easy task because the projects are given all sorts of different names, and published all over the world in all sorts of publications. We want to undertake a comprehensive search for these studies. We will do this using online and other computer-based methods, as well as reading through scientific journals and asking experts in this field. We will then judge which studies have been done well so that they provide the most accurate information. Finally, we will summarise what this research tells us and then recommend what actions UK schools and the government should take in the light of what we find. We have the expertise to do this work because our team is made up of health and education researchers, statisticians, information scientists and economists with relevant skills. And we have done similar sorts of work before. The work will cost about the same as other studies of this type and will be much cheaper than doing new research in schools to answer the same questions. When we publish our findings, we will be judged by the funder and other researchers on how carefully we undertook our research, how many studies we found and how we went about summarising them.
Abstract:	Methods: The review will involve 3 stages: 1) a descriptive map of available evidence, plus a preliminary synthesis of intervention logic models and theories of school-level effects on health; 2) in-depth reviews and syntheses of evidence addressing our research questions; and 3) drafting of final report and other dissemination. Target population and setting: Students, staff, parents and/or the local community of schools catering for those aged 4-18. Intervention being evaluated: School environment (SE) interventions aiming to change the physical, social or cultural environment within schools to promote health. Search strategy: In stage 1, we will include studies pertinent to our research questions: (RQ1) literature describing/explaining the theories and conceptual frameworks that are used to inform SE interventions or explain school-level influences on health; (RQ2) evaluation studies reporting on SE intervention effects on health, as well as cost, economic and econometric studies examining the costs of SE interventions; (RQ3) process evaluations of SE interventions; (RQ4) multi-level and ecological (school) studies of school-level influences on health; and (RQ5) qualitative studies exploring the processes by which school-level factors might influence health. We will search bibliographic databases and specialist registers; hand-search relevant websites and approximately five selected journals; consult with key education and child/adolescent health researchers; track citations and check reference lists of found reports; and incorporate found keywords into revised searches. Review process: Stage 1: Full reports will be obtained for those references meeting stage 1 inclusion criteria on the basis of title or abstract, or those where there is insufficient information from title and abstract to judge. Inclusion criteria will then be applied independently to each full report by two reviewers, with recourse to a third where necessary. Included studies will be described by applying a standard system supplemented by additional codes for this review. For an initial sample, two reviewers will code independently, drawing on a third as necessary. Subsequent coding will be done by one reviewer checked by another. We will thus develop a map of existing evidence. We will also undertake a preliminary synthesis of literature addressing RQ1 using thematic synthesis methods. This will inform the development of a priori hypotheses about how SE interventions and school-level influences impact on health, to be tested, if data allows, in stage 2. We will consult stakeholders on our evidence map and preliminary synthesis to inform our hypotheses and determine priorities for stage 2 syntheses. Stage 2: Draft inclusion criteria for stage 2: RQ1 - already synthesised in stage 1; RQ2 - prospective design, comparison groups, pre-determined outcomes, control for clustering, control of confounding, no over-adjustment, reporting on attrition (cost/economic/econometric studies will not be excluded on the basis of quality but will be quality-assessed and findings weighted); RQ3 - process evaluations - not excluded but quality-assessed as above; and RQ4 - control for school-level clustering and confounding, no over-adjustment, reporting on attrition (if sufficient studies, multi-level, longitudinal studies only); RQ5 - qualitative studies - not excluded but quality-assessed as above. Stage 2 criteria will be piloted then pairs of reviewers will work independently before agreeing to include/exclude studies, involving a third where necessary. For all studies we will extract data on: research questions/hypotheses; site and population; sampling; data collection methods; analysis methods; results; and authors' conclusions . Additional data will be collected specific to each study types (see proposal). Evidence from quantitative research addressing RQs 2 and 4 will be synthesised via statistical meta-analysis where there is sufficient homogeneity (see proposal). Where significant heterogeneity exists, and with qualitative studies addressing RQs 3 and 5, evidence will be narratively synthesised. Synthesis of economic evidence will depend on what evidence we find guided by our health economist (see proposal). We anticipate a limited narrative synthesis focused largely on cost. Stage 3: We will summarise our five individual syntheses in a draft report to address our over-arching aim, and consult with stakeholders to review and revise our draft report. Expected outputs of research: project report to funders published on-line; at least two journal articles; at least one conference presentation; plus dissemination to policy-makers and practitioners. Project timetable: Apr-Jun 2010: Finalise methods, recruit staff; May-Aug 2010: Retrieval of papers; Aug-Nov 2010: Evidence maps and preliminary synthesis of RQ1 evidence; Dec 2010: Stakeholder consultation; Dec 2010-Feb 2011: Identification and data extraction from high-quality studies; Mar-Jun 2011: Completion of syntheses addressing RQs1-5; May-Aug 2011: Drafting of final report and stakeholder consultation; Jul-Sep 2011: Final report submission plus other dissemination.
Protocol:	Access protocol
Cost:	£182,641

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The Public Health Research programme is managed by the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC). NETSCC is part of the University of Southampton.The NIHR Public Health Research programme is funded by the NIHR, with contributions from the CSO in Scotland, NISCHR in Wales and HSC R&D, Public Health Agency, Northern Ireland.