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Systematic review of the effects of schools and school environment interventions on health: evidence mapping and synthesis

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Bonell, C, Jamal, F, Harden, A, Wells, H, Parry, W, Fletcher, A, Petticrew, M, Thomas, J +4 more·2013·Public Health Research
DOI 10.3310/phr01010
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Abstract

Background: In contrast to curriculum-based health education interventions in schools, the school environment approach promotes health by modifying schools' physical/social environment. This systematic review reports on the health effects of the school environment and processes by which these might occur. It includes theories, intervention outcome and process evaluations, quantitative studies and qualitative studies. Research questions: Research question (RQ)1: What theories are used to inform school environment interventions or explain school-level health influences? What testable hypotheses are suggested? RQ2: What are the effects on student health/inequalities of school environment interventions addressing organisation/management; teaching/pastoral care/discipline; and the physical environment? What are the costs? RQ3: How feasible/acceptable and context dependent are such interventions? RQ4: What are the effects on student health/inequalities of school-level measures of organisation/management; teaching/pastoral care/discipline; and the physical environment? RQ5: Through what processes might such influences occur? Data sources: A total of 16 databases were searched between 30 July 2010 and 23 September 2010 to identify relevant studies, including the British Educational Index, the Cumulative Index to Nursing and Allied Health Literature, the Health Management Information Consortium, EMBASE, MEDLINE and PsycINFO. In addition, references of included studies were checked and authors contacted. Review methods: In stage 1, we mapped references concerning how the school environment affects health and consulted stakeholders to identify stage 2 priorities. In stage 2, we undertook five reviews corresponding to our RQs. Results: Stage 1: A total of 82,775 references were retrieved and 1144 were descriptively mapped. Stage 2: A total of 24 theories were identified (RQ1). The human functioning and school organisation, social capital and social development theories were judged most useful. Ten outcome evaluations were included (RQ2). Four US randomised controlled trials (RCTs) and one UK quasi-experimental study examined interventions building school community/relationships. Studies reported benefits for some, but not all outcomes (e.g. aggression, conflict resolution, emotional health). Two US RCTs assessed interventions empowering students to contribute to modifying food/physical activity environments, reporting benefits for physical activity but not for diet. Three UK quasi-experimental evaluations examined playground improvements, reporting mixed findings, with benefits being greater for younger children and longer break times. Six process evaluations (RQ3) reported positively. One study suggested that implementation was facilitated when this built on existing ethos and when senior staff were supportive. We reviewed 42 multilevel studies, confining narrative synthesis to 10 that appropriately adjusted for confounders. Four UK/US reports suggested that schools with higher value-added attainment/attendance had lower rates of substance use and fighting. Three reports from different countries examined school policies on smoking/alcohol, with mixed results. One US study found that schools with more unobservable/unsupervised places reported increased substance use. Another US study reported that school size, age structure and staffing ratio did not correlate with student drinking. Twenty-one qualitative reports from different countries (RQ5) suggested that disengagement, lack of safety and lack of participation in decisions may predispose students to engage in health risks. Limitations: We found no evidence regarding health inequalities or cost, and could not undertake meta-analysis. Conclusions: There is non-definitive evidence for the feasibility and effectiveness of school environment interventions involving community/relationship building, empowering student participation in modifying schools' food/physical activity environments, and playground improvements. Multilevel studies suggest that schools that add value educationally may promote student health. Qualitative studies suggest pathways underlying these effects. This evidence lends broad support to theories of social development, social capital and human functioning and school organisation. Further trials to examine the effects of school environment modifications on student health are recommended. Funding: The National Institute for Health Research Public Health Research programme.

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  1. DOI: 10.3310/phr01010 PUBLIC HEALTH RESEARCH 2013 VOL. 1 NO. 1
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  17. DOI: 10.3310/phr01010 PUBLIC HEALTH RESEARCH 2013 VOL. 1 NO. 1 Appendix A Searches TABLE 1 Search (1): Medline core search strategy (29 July 2010)

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Authors
Bonell, C., Jamal, F., Harden, A., Wells, H., Parry, W., Fletcher, A., Petticrew, M., Thomas, J., Whitehead, M., Campbell, R., Murphy, S., & Moore, L.
Affiliations
  • University of Oxford (GB)
  • University of East London (GB)
  • London School of Hygiene & Tropical Medicine (GB)
  • University of London (GB)
  • Cardiff University (GB)
  • University of Liverpool (GB)
  • University of Bristol (GB)
Corresponding author
Bonell, C
ORCID
Venue
Public Health Research
Publisher
National Institute for Health and Care Research
Published
2013-06
Volume
1
Issue
1
Pages
1-320
ISSN
  • 2050-4381 (ISSN-L)
  • 2050-439X
DOI
10.3310/phr01010
OpenAlex
W2032716838
Cited by
192
References
169
Citations by year
2026: 3 · 2025: 12 · 2024: 12 · 2023: 14 · 2022: 15 · 2021: 9 · 2020: 17 · 2019: 25 · 2018: 15 · 2017: 17 · 2016: 24 · 2015: 17 · 2014: 8 · 2013: 3 · 2012: 1
FWCI
3.07
Type
journal article
Language
en
Open access
Licence
www.nationalarchives.gov.uk/doc/non-commercial-government-licence/non-commercial-government-licence.htm (unspecified)
Locations
  • Public Health Research (publishedVersion)
  • ORCA Online Research @Cardiff (Cardiff University) (acceptedVersion)
  • UEL Research Repository (University of East London) (acceptedVersion)
  • UEL Research Repository (University of East London) (submittedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Explore Bristol Research (submittedVersion)
Funders
National Institute for Health Research (09/3002/08)
Topics
  • Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
  • Social Sciences › Education › Educational Environments and Student Outcomes
  • Health Sciences › Health Professions › General Health Professions › Adolescent Health and Behaviors
Keywords
student health, health disparities, pastoral care, student discipline, school space, school food environment, physical activity, social capital, social development theory, implementation barriers and facilitators, intervention costs, school community building, student empowerment, stakeholder engagement, evidence mapping

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