The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 04/2014; 4(4):CD008958. DOI: 10.1002/14651858.CD008958.pub2
Source: PubMed


The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.
To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.
We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland,, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.
We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.
At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.
We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.
The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

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Available from: Theodora Pouliou, Nov 01, 2014
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    • "Additionally, childhood obesity was responsible for $14.1 billion in direct medical costs annually (2002–2005) (Trasande & Chatterjee, 2009). An early implementation of evidence-based health promotion in childhood could help to reverse the trend, but successful and cost-effective programs are rare (Waters et al., 2011; Langford et al., 2014). For abdominal obesity in children, it is crucial to find associated factors that are modifiable and can be targeted by preventive measures. "
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    ABSTRACT: Objective: To investigate correlates of changes in waist-to-height ratio (WHtR) in primary school children in order to identify modifiable factors usable for prevention. Methods: Outcome evaluation of a statewide health promotion program in Baden-Württemberg, Germany. Baseline (2010) and follow-up (2011) measurements provided data for the calculation of changes in WHtR. Further information on the health and living conditions of the children were assessed in parental questionnaires. Anthropometric measures were taken in 1733 (50.8% male) first and second grade children (age at baseline 7.1 ± 0.6 years) by staff trained according to ISAK-standards. Stepwise linear regression analysis was applied to identify variables with influence on changes in WHtR. Results: According to the resulting regression model, changes in WHtR towards an increase were influenced by at least one parent being overweight/obese, at least one parent who smoked, low household income, higher age of the child and the skipping of breakfast. There was no clustering effect in schools observed. Conclusion: A promising target for prevention of gain in WHtR in primary school children is to ensure the regularity of breakfast. Smoking cessation as well as dietary improvements would not only help children's health but also the health of their parents. The socioeconomic influence on the development of an unhealthy weight status has already been acknowledged and should be extensively targeted by all of society and policy makers.
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    • "This would be consistent with the World Health Organisation concept of Health Promoting Schools (HPS), where children not only learn about healthy behaviours but the school environment is also supportive of healthy behaviours, by, for example, providing secure cycle racks, safe routes (car limited or free) to and from school and healthy foods in canteens. A recent systematic review of the effect of schools adopting the HPS framework identified some positive effects but also noted the need for more robust, high quality evaluation research in this area [47]. There is also evidence that food policy, such as increasing taxes on high sugar foods, is effective in changing children's diets to healthier ones, but the extent to which politicians will engage with these is unclear [48]. "
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    ABSTRACT: Background: Active for life year 5 (AFLY5) is a school-based intervention, based on social cognitive theory, which aims to promote healthy levels of physical activity and healthy eating by improving a child's self-efficacy to make healthy choices, their knowledge of how to make such choices and prompting parents to support their children to make healthy choices. Previously published results showed no effect on the three primary outcomes and beneficial effects on three of nine secondary outcomes (time spent screen-viewing at weekends, consumption of snacks and of high energy drinks). This paper aims to determine the effect of the intervention on potential mediators. Methods: We conducted a cluster RCT of a school-based intervention, with allocation concealed by use of a remote system. The study was undertaken in the South West of England between 2011 and 2013. Participants were school children who were age 8-9 years at baseline assessment and 9-10 years during the intervention. Potential mediators were assessed at the end of the intervention. The intervention consisted of teacher training, provision of all materials required for lessons and homeworks and written materials for school newsletters and parents. The ten potential mediators were child-reported self-efficacy for physical activity and fruit and vegetable consumption, perceived parental logistic support and modelling for their child's physical activity, parental efforts to limit their child's sedentary behaviour and modelling of healthy fruit and vegetable consumption, together with a knowledge assessment. Results: We successfully recruited 60 schools with over 2,221 children; valid data for the 10 mediators were available for 87 % to 96 % of participants. Three of the ten potential mediators were greater in the intervention, compared with the control group: fruit and vegetable self-efficacy 2.2 units (95 % CI: 0.7 to 3.8), assessed on a scale 26 to 130; child-reported maternal limitation of sedentary behaviour 0.5 (0.1 to 0.8), scale 4 to 16; and knowledge 0.5 (0.2, 0.7) scale 0 to 9. Reported maternal limitation of sedentary behaviour and the child's knowledge explained 23 % of the effect of the intervention on reducing time spent on sedentary behaviour at the weekend. There was no effect on other mediators. Conclusions: Our findings suggest that the effect of the AFLY5 intervention on reducing screen-viewing at weekends was partially mediated by an effect on mothers limiting their child's time spent sedentary and on increasing the child's knowledge about healthy behaviour. However, overall our findings suggest that theory driven interventions, like AFLY5, can fail to influence most potential mediators and this may explain the failure of the intervention to improve most primary and secondary outcomes. Trial registration: Current Controlled Trials ISRCTN50133740 . Registered 17/03/2011.
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    • "Trotz seiner Beliebtheit lässt sich bislang ein Mangel an Wirksamkeitsnachweisen zu diesem Ansatz konstatieren. Partiell positive Evidenz findet sich in einem aktuellen Cochrane Review, innerhalb dessen auf Basis einer systematischen und kriteriengeleiteten Datenbankrecherche 67 cluster-randomisierte Studien analysiert wurden (Langford et al. 2014 "
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    ABSTRACT: Based on the adoption of the Ottawa Charta for health promotion, schools have long been established as a key setting for the promotion of young peoples and teachers’ health during the past decades. At a conceptual level, different approaches can be distinguished, which focus on the individual as well as their behavior and on the school environment and its development. In recent years, it is increasingly argued that school health promotion has to align itself to educational quality. This article gives an overview of the development of school health promotion and its implementation in Germany. Moreover, based on the current research discussion and practical experience six future challenges are introduced, which need to be addressed to further develop school health promotion in future.
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