Title slide

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The Evidence Base for Health Promotion in
Schools What does it tell us and what does it
not?
Sarah Stewart-Brown Professor of Public
Health Director Health Sciences Research
Institute Warwick Medical School
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Plan
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Plan 1

• Findings from Reviews of Reviews of Health
  Promotion in Schools
• Health promoting schools and health promotion in
  schools two systematic reviews. Lister Sharpe
  et. al. Health Technology Assessment 1999(3) 22
• What is the evidence on school health promotion
  in improving health or preventing disease, and
  specifically, what is the effectiveness of the
  health promoting school approach. Stewart-Brown
  2006
• Health Evidence Network WHO Europe
  http//www.euro.who.int/document/e88185.pdf

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Plan 2

• Recent reviews of mental health promotion in
  schools
• Systematic Review of the effectiveness of
  interventions to promote mental wellbeing in
  children in primary education.
• Report 1 universal approaches non violence
  related outcomes National Institute for Health
  and Clinical Excellence June 2007
• http//www.nice.org.uk/guidance/index.jsp?action
  downloado43911
• Systematic Review of the effectiveness of
  interventions to promote mental wellbeing in
  primary schools. Report 3 universal approaches
  which focus on prevention of violence and
  bullying NICE Sept 2007
• http//www.nice.org.uk/guidance/index.jsp?action
  downloado43912
• Mental wellbeing of children in primary
  education targeted /indicated activities NICE
  July 2007
• http//guidance.nice.org.uk/download.aspx?o441004
  

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Plan 3

• Reflect on lessons from these reviews
• Reflect on future directions for school health
  promotion in Europe

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Some Caveats

• My background
• Limitations of review level evidence

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Review level evidence

• Places more emphasis on the quality of the study
  than on the quality of the programme or
  intervention
• It is often difficult to discover from reviews
  exactly what was involved in successful
  programmes or intervention

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• In the field of health promotion
• Randomised controlled trials are inappropriate
  misleading and unnecessarily expensive
• WHO European Working Group on Health Promotion
  Evaluation 1998 EUR/ICP/IVST 05 0103
  CopenhagenWHO Regional policy for Europe

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• In the field of health promotion
• Randomised controlled trials are inappropriate
  misleading and unnecessarily expensive
• WHO European Working Group on Health Promotion
  Evaluation 1998 EUR/ICP/IVST 05 0103
  CopenhagenWHO Regional policy for Europe
• In the field of policy making
• Interventions which have not been subject to
  randomised controlled trials are regarded as
  unproven

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New UK Medical Research Council Guidance on
developing and evaluation complex interventions
Feasibility and piloting
Evaluation
Development
Implementation
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New UK MRC Guidance on developing and evaluation
complex interventions

• Evaluation phases do not have to follow a linear
  sequence
• Experimental designs, though preferred are
• recognised as sometimes impractical
• Complex interventions may work better if tailored
  to local circumstances ie not standardised
• Process evaluation important alongside outcome

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Systematic Reviews

• Strengths
• Comprehensive
• Controlled studies
• Clear inclusion criteria
• Critical appraisal
• Weaknesses
• Only include experimental studies
• Limited to quantitative outcomes
• Information about programme implementation and
  content often scant
• Limited by inclusion / exclusion criteria

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Health promoting schools and health promotion in
schools two systematic reviews. HTA 1999(3) 22

• Two Reviews
• Review of Primary Studies of Health Promoting
  Schools
• Review of Reviews of Health Promotion in Schools
• All experimental studies before and after and
  controlled
• All good quality systematic reviews

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Systematic Reviews of Health Promotion in Schools
Substance use
Mental health
Sexual health
Nutrition exercise
Accident prevention
Other
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Systematic Reviews of Health Promotion in
Schools 1999

• HP in schools not reliably effective
• Most interventions classroom based, but
  successful interventions more likely to include
• an environmental component
• and/or family or community component

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Systematic Reviews of Health Promotion in Schools
1999

• Among classroom based interventions
• Knowledge easy to change
• Behaviour and attitudes much harder to influence
• Healthy eating and physical activity programmes
  more successful that drug or alcohol misuse
  programmes
• Programmes incorporating life skills education
  and involving peers more promising than those
  that didnt

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What is the evidence on school health promotion
in improving health or preventing disease, and
specifically, what is the effectiveness of the
health promoting school approach. Sarah
Stewart-Brown Health Evidence Network WHO 2006

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What is the evidence on school health promotion
in improving health or preventing disease, and
specifically, what is the effectiveness of the
health promoting school approach. HEN WHO 2006

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4
N. of Reviews
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Aspects of Mental Health HEN Report WHO 2006

• Prevention
• Antisocial behaviour
• Criminality/ violence
• Bullying
• Depression
• Suicide
• Anxiety

• Promotion
• Self esteem
• Social skills
• Problem solving
• Conflict resolution
• Emotional literacy
• Peer relationships

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HEN Review Results

• Mental health promotion programmes are effective,
  particularly if they
• Involve the whole school
• Make changes to psychosocial environment
• Personal skill development
• Involvement of parents and wider community
• Implement over long period of time
• Moderate to large effect sizes reported

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HEN Review Results

• Healthy Eating and Physical Activity Programmes
• Amongst the most sophisticated
• Effective if involved changes to school
  environment
• Involved parents and wider community
• A range of different type of programme proved
  effective

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HEN Review Results

• Substance use programmes were the least
  effective. At best they
• delay onset
• reduce quantity of drugs consumed
• No new reviews of safe sex programmes
• Driver education ineffective

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• Systematic Reviews of the effectiveness of
  interventions to promote mental wellbeing in
  children in primary education. NICE 2007
• Universal approaches
• Report 1- focus on non- violence related
  outcomes and
• Report 3- focus on prevention of violence and
  bullying
• Targeted approaches
• Report 2- Mental Wellbeing in primary education
  targeted indicated activities

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Population Approaches
Number of Individuals
Decreasing level of health problem
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Targeted/indicated approaches
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Targeted/indicated approaches
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Universal approaches
Population mean
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Universal approaches
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NIHCE Reviews of approaches to mental health
promotion in primary schools

• A significant evidence base exists
• Universal
• 23 Randomised Controlled Trials
• 21 Controlled Trials
• Targeted
• 27 Randomsed Controlled Trials
• 1 Controlled Trial
• Health Economic
• 0

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NIHCE Reviews of approaches to mental health
promotion in primary schools

• Great majority of studies carried out in US
• Germany (3)
• Stress management x 2 (Lohaus 1997, 2000)
• Qi Gong (Witt 2005)
• Netherlands (2)
• Good Behaviour Game (Van Lier 2005)
• UK (1)
• Emotional disclosure (Reynolds 2000)
• Spain (1)
• Targeted ADHD prog (Miranda 2002)
• Canada (7)
• Australia (5)

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NIHCE Reviews of approaches to mental health
promotion in primary schools

• Findings Universal-
• Wide range of interventions
• classified by component parts
• Only three interventions evaluated in more than
  one study.
• Some interventions trialled with and without
  additional components, but not in the same study.
  
• Study quality variable

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NIHCE Reviews of approaches to mental health
promotion in primary schools

• Findings Universal
• Most universal interventions delivered by
  teachers
• Some peer mentoring
• Some psychologist delivery
• Some combined with targeted approaches
• High proportion of targeted interventions
  delivered by psychologists
• Predominant focus antisocial behaviour and social
  skills
• Some studies investigated- anxiety, depression,
  self concept, self esteem, peer relationships

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Findings Universal-

• Description of Programmes
• Primarily curriculum (14)
• Social skills, conflict management, problem
  solving, emotional literacy, coping
• CB skills, Relaxation
• eg PATHS, Second Step
• Primarily behaviour management (6)
• Teachers trained to manage behaviour in and
  outside classroom
• Resources and games
• eg Good Behaviour Game Peace Builders

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Findings Universal-

• Description of Programmes
• Primarily anti- bullying (3)
• Increased awareness
• Reporting
• Confronting
• Olweus (Bullyproof your school)
• Multi-component (16)
• Curriculum, behaviour management, parenting
  support
• eg LIFT, Resolving Conflict Creatively
• As above plus changes to the school ethos and
  environment
• Eg Seattle Social Development,

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Outcome by type of Universal Intervention
Curriculum
Parenting plus
Whole school
Other
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Good Quality Studies of Effective Universal
Interventions

• Tri Ministry Study Canada Boyle 1999
• Social skills training, teacher training, support
  for parenting (2 years)
• PATHS plus parenting (CPPRG 1999)
• Emotional literacy curriculum (57 lessons),
  teacher training on programme and behaviour
  support for parenting
• Seattle Social Development Project (Hawkins
  1991,1999 2005)
• Teacher training in behaviour management and
  modelling, social skills, parenting support
  (Permanent change)
• LIFT programme (Reid Eddy Stoolmiller 1999-)
• Parenting programme, social skills curriculum,
  Good Behaviour Game (3 months)
• Peace Builders (Vazsonyi 2004, Krug 1997)
• Cultural change to school five principles, peer
  mentoring, parenting support, peer mentoring
  (Permanent change)

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Findings Targeted

• Mostly delivered by psychologists
• Short CBT based programmes for anxiety
• better with parenting education
• Multi-component approaches including parenting
  component for externalising behaviours
• May be recruitment problems with parenting
  education

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Messages

• Evidence of effect
• Need for multiple components
• Teacher development
• Parenting support
• School ethos
• Balance of universal and targeted
• Balance of teacher delivered and specialist
  delivered

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Mental Health in Schools

Pupil aggressive behaviour
Teacher aggressive behaviour
School Ethos
Teacher depression and anxiety
Pupil depression and anxiety
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hippocampus
orbitofrontal cortex
amygdala
hypothalamus
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Brain Development

• The emotional and social brain is developed and
  sustained in the context of interpersonal
  relationships
• The parent-child relationship is critical because
  children spend most time with their parents good
  quality relationships enable the child to develop
  self soothing
• Early relationships set the thermostat on the
  stress response influencing a range of
  physiological processes and increasing the risk
  of disease
• Early relationships set the scene for future
  relationships including parents relationships
  with their own children

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Brain Development

• By school age emotional and social responses to
  threat are ingrained in the brain
• Relationships with teachers can enable these
  pathways to change and help vulnerable children
  develop the capacity to self sooth
• The older the child the greater the skill of the
  teacher
• The skills teachers need to form therapeutic
  relationships require robust mental health
• The proportion of the adult population with
  really robust mental health is small

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What promotes mental wellbeing in adulthood ?

• Good social support
• Respectful, empathetic relationships
• Physical activity
• Creative activity
• Meditation mindfulness practices

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A view on the way forward for Health Promoting
Schools

• Put mental health promotion centre stage
• Work on emotional and social aspects of school
  ethos and environment
• Support teachers mental health and emotional and
  social development

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A view on the way forward for Health Promoting
Schools

• Introduce mindfulness practices
• Meditation, Yoga, Qi Gong
• Increase physical activity
• Improve diet
• Increase creative activity

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Thank you for listening