What’s your response to the ‘back to school’ slogan splayed across our shops from the beginning of the summer break? Every parent will have one and many besides may be prompted to give silent thanks that schooldays are behind them, or maybe to recall them with fondness. For me, Mum to two teenage girls, my first thought is the annual battle with rolls of sticky-backed plastic. Elder daughter is a Sticky-backed Plastic Whisperer, producing crease-free, perfect covers. The other succeeded, last year, in sticking the stuff to two books at once, to my work and, finally, to the cat. ‘Back to school’ also means I have to start worrying (again) about whether they’ll be happy, or at least ok; whether they’ll feel safe at school and about what pressures they’ll be under to make choices that aren’t good for their health and wellbeing. Then I can think about how far they’re on track to do well in their GCSEs. Sound familiar?
In England, education policy has moved away from an emphasis on wellbeing, social and emotional development and healthy behaviours to focus primarily on academic attainment. Ofsted (the Office for Standards in Education) inspects schools now with a narrower focus than in previous years and how well schools educate and nurture their students beyond the confines of the academic curriculum seems to have slipped from view.
A recent editorial in the BMJ pointed out that the idea that time spent on health and wellbeing means less time for academic pursuits and therefore poorer results is flawed and that countries such as Australia and Sweden, where students’ general development receives more attention in schools, also enjoy better academic success. Conversations quickly reveal that many of us think that children are more likely to learn better in an environment which supports their general wellbeing as well as enjoying other benefits. Do we have any evidence for it? Cue the Health Promoting School and what we know about how this approach impacts on health, wellbeing and learning.
What is a health promoting school?
Back in the late ’80s, the World Health Organization (WHO) developed the idea of the ‘Health Promoting School’ (HPS), where health and wellbeing are fostered through the whole school environment and not just in the curriculum. There’s no strict definition adopted by all, but key elements are:
- formal health curriculum
- ethos and environment of the school promotes health and wellbeing
- engagement with families and/or communities
Fifteen years ago, I was part of a team conducting a systematic review on the effectiveness of this approach for improving health. We found indications that it was promising and warranted further development. We didn’t look at its impact on educational attainment. Earlier this year, a new Cochrane review was published which aimed to assess the effectiveness of the HPS approach for improving the health and wellbeing of students and their academic achievement. The reviewers found 67 eligible cluster trials (1345 schools and 98 districts were randomised). Only ten were explicitly based on the HPS framework but to be included in the review they had to address all three points above. Programmes varied in the aspects of health tackled. The evidence was assessed as being of low to moderate quality and future studies are likely to change the results.
Here’s what they found:
Physical activity and nutrition interventions appear to lead students to increase their moderate-to-vigorous physical activity by around three minutes a day as well as their fitness, increases which have the potential to produce public health benefits at the population level. The results are in line with those of another Cochrane review which assessed all types of school-based interventions to increase physical activity.
More fruit and veg
Interventions focusing solely on diet produced an increase in fruit and vegetable intake of 30g a day, about half a portion. No improvement was found when diet and exercise were tackled together and nor did these bring about reductions in fat intake.
There were mixed results for programmes that targeted smoking but those that tackled this alone found students were 23% less likely to smoke at follow-up compared with students not involved in the programme. Tackling multiple risk behaviours was also effective.
- Small, positive effects for body mass index (BMI), but not when when age and gender were taken into account
- Some evidence that HPS interventions may reduce bullying
- No evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence
- Not enough data to draw conclusions about effectiveness for sexual health, hand-washing, cycle helmet wearing, eating disorders, sun protection, oral health, attendance or academic success
The authors conclude that “our review demonstrates the potential benefit of this approach for health. We have yet to see its benefit for education.” It’s disappointing that we’re still in the dark about whether promoting health and wellbeing in the ways studied here translates into higher achievement, nor even if it can improve school attendance. Few studies looked at this, which feels like a missed opportunity. It’s also surprising, given that the HPS framework is based on the recognition of a relationship between health and education. Future research must surely address this as evidence of educational improvements are, as the authors point out, likely to be an important factor in determining whether investment is made in these interventions.
A Cochrane review published earlier this year, on whether lifestyle interventions for overweight and obese children could improve school achievement, also found that this evidence is lacking despite the large number of childhood obesity treatment trials. There’s some evidence that multicomponent interventions targeting physical activity and healthy diet could benefit general school achievement, while a physical activity intervention delivered for childhood weight management could benefit mathematics achievement, executive function and working memory. We need to more and better evidence.
Beyond sex and drugs
There are other very significant gaps too, on those other important topics listed above, from sex to mental health. How, whether and when schools tackle these will be part of political debate in the run-up to the next election, of course, with the latest being a call by the Liberal Democrats for “age-appropriate” sex education to be taught from the age of seven. This week also saw a new report on young people, sex and relationships. The survey of 500 teens, conducted by the Institute for Public Policy Research, found that these young people feel they need more information and support in every aspect of sex and relationship education; that the majority would like it taught by a trained expert, and that a broader focus is warranted ‘to cover the wider wellbeing aspects of healthy, positive intimate and social relationships.’.
It was really interesting to talk about this with my teenage girls and their friends, about to start years 10, 11 and 12 at two different senior schools. Their views bore out what this survey found. They would like more PHSE lessons than their current hour a fortnight, taught with up-to-date materials to which they can relate, covering a wider range of topics. “We do loads on drugs but nothing on relationships. Lots of us would never do drugs but we’ll all have relationships. We never do anything on body image and that’s really important.” “We should have more sex education lessons, definitely! The boys are under so much pressure from other boys to have sex. It’s different for girls though.” “We need to know what’s legal at different ages, in terms of sex, alcohol and smoking. It’s really confusing. It would be good to have this kind of information in our homework diaries.” Like many of those in the survey, they would much prefer to be taught by people from outside school, who are trained specialists or have personal experiences to share. “It would be really interesting to hear from people who have taken drugs and who it went wrong for. We’d have more respect for them. It would have such a lot of impact if someone came in to talk about their experience.” “It’s really awkward if it’s one of your teachers. It’s like ‘we don’t want to know about your periods or your sex life and we don’t want to tell you about ours!’ When we had someone come from a sexual health clinic it was really good.”
Body image is highlighted in The Good Childhood Report 2014, published yesterday, which has the latest findings from this nine year programme of research on how children feel about their lives. In terms of happiness with appearance children in England fare particularly poorly compared to the other countries in the study, with girls more unhappy than boys, though generally they are a little happier with school. The report also says that children who are regularly active have higher well-being compared to children who are not and, interestingly, children who use computers and the internet regularly have higher well-being than children who do not. We should be concerned that overall children in England ranked 30th out of 39 countries in Europe and North America and ninth out of a sample of 11 countries around the world.
When life is even tougher…
For those children living with a chronic condition, school presents additional challenges, from the safety of the environment to helping them fulfil their potential and to manage their health and wellbeing. Check back next Friday for the second of our back to school blogs, written by nine year old Tess, who has Cystic Fibrosis. She tells us what what her normal school day looks like, what the dangers are, how her peers have supported her and her wish list for school. Don’t miss it!
Back to school: better health, better learning infographic: http://www.evidentlycochrane.net/back-to-school-infographic/
Editorial: Why schools should promote students’ health and wellbeing. BMJ 2014;348:g3078
Lister-Sharp D, Chapman S, Stewart-Brown S, Sowden A. Health promoting schools and health promotion in schools: two systematic reviews. Health Technol Assess. 1999;3(22):1-207
Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD007651. DOI: 10.1002/14651858.CD007651.pub2.
Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, Komro KA, Gibbs LF, Magnus D, Campbell R. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008958. DOI: 10.1002/14651858.CD008958.pub2.
Martin A, Saunders DH, Shenkin SD, Sproule J. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD009728. DOI: 10.1002/14651858.CD009728.pub2.The Guardian, Tuesday 26th August 2014. Sex education should begin at seven, claim Lib Dems. Available online at http://www.theguardian.com/education/2014/aug/26/sex-education-begin-seven-schools-lib-dems
Parker I. Young people, sex and relationships: the new norms. London: Institute for Public Policy Research; August, 2014. Available from: http://www.ippr.org/assets/media/publications/pdf/young-people-sex-relationships_Aug2014.pdf
Pople L, Raws P, Mueller D, Mahony S, Rees G, Bradshaw J, Main G, Keung A. The Good Childhood Report 2014 [dynamic online version]. London: The Children’s Society and University of York; August, 2014. Available from: http://goodchildhood.childrenssociety.org.uk/