Theories of how the school environment impacts on student health: systematic review and synthesis

Positive childhood experiences in mental health of young adults across adverse childhood experiences levels: A study from Delhi-NCR, India

BACKGROUND

While the impact of adverse childhood experiences (ACEs) on adult health outcomes has received substantial scientific attention, the role of positive childhood experiences (PCEs) has far less widely been explored, especially in low- and middle-income countries.

OBJECTIVE

The present study aimed to understand the association of exposure to cumulative and individual PCEs with current depression, anxiety, stress, and well-being among young adults in Delhi-NCR, India, independently and across ACE exposure levels.

PARTICIPANTS AND SETTING

This cross-sectional study involved 1553 young adults (aged 18-25) of both sexes (70.3 % females) residing in Delhi-NCR.

METHODS

PCEs and ACEs were measured using the Benevolent Childhood Experiences scale and ACE- International Questionnaire, respectively. Depression, anxiety, stress, and well-being were screened using validated tools.

RESULTS

In the overall analysis, exposure to PCEs was negatively associated with depression, anxiety, and stress and positively associated with well-being, even after accounting for ACEs. Feeling comfortable with oneself emerged as the most important PCE item with respect to studied mental health conditions. The stratified analysis showed that while the PCE score was associated only with depression (negatively) in the no ACE category, it was associated with all the studied outcome variables in higher ACE categories.

CONCLUSIONS

The study found PCEs to be associated with better mental health outcomes across varying ACE levels, with the protective effect being particularly pronounced in high ACE contexts. Promoting PCEs can help improve mental health outcomes and well-being despite adversities.

Adverse Childhood Experiences and Nonsuicidal Self-Injury and Suicidality in Chinese Adolescents

Importance

Studies investigating the role of supportive school environments in associations between adverse childhood experiences (ACEs) and nonsuicidal self-injury (NSSI) and suicidality among adolescents are lacking.

Objective

To assess associations of ACEs with NSSI and suicidality among adolescents and examine the modifying role of supportive school environments in such associations.

Design, Setting, and Participants

Using data from the 2021 School-Based Chinese Adolescents Health Survey, this cross-sectional study includes Chinese adolescents in grades 7 through 12 from 326 schools across 8 provinces in China. Statistical analysis was performed from March to October 2024.

Exposure

ACEs, including individual indicators and cumulative numbers by total and categorized as threat-related and deprivation-related ACEs, were assessed.

Main Outcome and Measures

NSSI, suicidal ideation, and suicide attempts were measured using validated questionnaires. Weighted Poisson regression models were used. The modifying interaction of supportive school environments was assessed using multiplicative interactions.

Results

Among 95 549 adolescents included in this study (mean [SD] age, 14.9 [1.8] years; 47 617 males [49.8%]), 45 236 individuals (47.3%) had experienced at least 1 ACE. Compared with adolescents with no ACEs, those who experienced 4 or more ACEs had an increased risk of NSSI (prevalence ratio [PR], 1.31; 95% CI, 1.30-1.33) and suicidality (ideation: PR, 1.41; 95% CI, 1.39-1.42; attempts: PR, 1.25; 95% CI, 1.24-1.27) after adjusting for covariates, including supportive school environments. A dose-response association was observed between the number of ACEs and the risk of NSSI and suicidality (eg, NSSI: PR, 1.06; 95% CI, 1.05-1.06 for exposure to 1 vs 0 ACEs; PR, 1.10; 95% CI, 1.10-1.11 for exposure to 2 vs 0 ACEs). The highest PRs were found for associations of threat-related ACEs (eg, physical abuse, emotional abuse, and bullying) with NSSI and suicidality (eg, exposure to ≥2 vs 0 threat-related ACEs: PR, 1.28; 95% CI, 1.27-1.29 for NSSI; PR, 1.33; 95% CI 1.32-1.34 for ideation; PR, 1.18; 95% CI, 1.17-1.19 for attempts). All individual ACE indicators were positively associated with NSSI and suicidality, with particularly high PRs for emotional abuse (eg, PR, 1.26; 95% CI, 1.24-1.27 for NSSI). Additionally, supportive school environments significantly modified associations of ACEs with NSSI and suicidality (eg, interaction ratio for NSSI, 0.81; 95% CI, 0.76-0.88).

Conclusion and relevance

In this study, exposure to ACEs was associated with an increased risk of NSSI and suicidality, with particularly high increases for threat-related ACEs, independent of the interaction of supportive school environments, but supportive school environments could modify such detrimental outcomes. These findings underscore the importance of enhancing school environments to prevent NSSI and suicidality among adolescents who have experienced ACEs.

Understanding Diagnosis Delay in Children With Cancer: Evidence From a Single Institution in Jordan

BACKGROUND

This study aimed to evaluate the factors associated with diagnosis delay in children with cancer who are treated at a single institution, which caters to most children with cancer in Jordan.

METHODS

This was a cross-sectional study with a retrospective chart review of selected patients who were diagnosed from August 2018 to December 2021. Data on patient and household characteristics, medical history, and diagnostic delay were collected through structured interviews. Univariable and multivariable linear and logistic regression models were used to identify predictors of delay.

RESULTS

The study included a cohort of 202 patient-caregiver pairs, with a median total delay from symptom onset to treatment initiation of 47 days (interquartile range [IQR], 21 to 114 d). Notably, 86% of families pursued medical consultation within a month of recognizing symptoms. A regression model revealed CNS tumors as a significant independent predictor of increased total delay ( P =0.002), with affected patients experiencing a median delay markedly longer than those with other cancer types. In addition, older patient age predicted longer total delay ( P =0.025). Symptomatology played a pivotal role in the timeliness of the diagnosis; specifically, visible symptoms such as pallor, bruises, and jaundice were associated with more expedient medical attention, with significantly shorter delays ( P values: 0.011, <0.001, and 0.045, respectively). Furthermore, our investigation disclosed a notable variance in symptom prevalence across different cancer categories, elucidating the complex relationship between clinical presentation and diagnostic timelines.

CONCLUSIONS

This study highlights the importance of the diagnosis of CNS tumors, patient age, and symptoms in predicting diagnosis delay in pediatric oncology patients. These findings can inform interventions to reduce delays in diagnosis and improve outcomes for these patients. These insights are crucial for developing targeted educational programs aimed at healthcare professionals and families to accelerate the recognition and referral of pediatric cancer cases.

Are educational aspirations associated with susceptibility to smoking, e-cigarette use, and smokeless tobacco use in adolescence?

The early socio-economic differences in smoking build on the interplay between individual-, family-, peer-, and school-related factors. The present study aimed to add knowledge to this by examining susceptibility to smoking (S-SM), electronic cigarette (e-cigarette) use (S-EC), and smokeless tobacco (snus) use (S-SN) by educational aspirations in a country with advanced tobacco control policies. National cross-sectional School Health Promotion study survey was conducted among 8.-9. grade students (av. 15-year-olds) in 2017 with no prior smoking (n = 47 589), e-cigarette use (n = 49 382), or snus use (n = 53 335). Gender-stratified, age-adjusted multilevel logistic regression analyses with S-SM, S-EC, and S-SN were considered as outcomes and student- and school-level (aggregated) factors were considered as independent variables. The highest prevalence was observed for S-EC (girls 29%, boys 35%), followed by S-SM (16%, 15%) and S-SN (10%, 16%). Compared to those planning for general upper secondary education, S-SM was the highest for those without educational aspirations (OR = 1.20, 95% CI = 1.04-1.40), S-EC for those planning for vocational education [1.15 (1.05-1.25)], and S-SN for those planning for extra year/discontinuation [1.65 (1.04-2.60)] among girls. Among boys, both S-SM [1.37 (1.23-1.52)] and S-EC [1.19 (1.09-1.29)] were the highest among those planning for vocational education, with no clear associations with S-SN. Current other tobacco/e-cigarette use [OR range 1.27-8.87], positive attitude towards product use in one's age group [3.55-6.63], and liking school [0.58-0.68] consistently associated with susceptibility. Students not planning for academically oriented education had higher susceptibility to different nicotine products. High S-EC warrants monitoring to strengthen policy evaluation and prevention.

The Social and Emotional Education and Development intervention to address wellbeing in primary school age children: the SEED cluster RCT

Background

Stronger social and emotional well-being during primary school is positively associated with the health and educational outcomes of young people. However, there is little evidence on which programmes are the most effective for improving social and emotional well-being.

Objective

The objective was to rigorously evaluate the Social and Emotional Education and Development (SEED) intervention process for improving pupils' social and emotional well-being.

Design

This was a stratified cluster randomised controlled trial with embedded process and economic evaluations. Thirty-eight primary schools were randomly assigned to the SEED intervention or to the control group. Hierarchical regression analysis allowing for clustering at school learning community level was conducted in R (statistical package).

Setting

The SEED intervention is a whole-school intervention; it involved all school staff and two cohorts of pupils, one starting at 4 or 5 years of age and the second starting at 8 or 9 years of age, across all 38 schools.

Participants

A total of 2639 pupils in Scotland.

Intervention

The SEED intervention used an iterative process that involved three components to facilitate selection and implementation of school-based actions: (1) questionnaire completion, (2) benchmarked feedback to all staff and (3) reflective discussions (all staff and an educational psychologist).

Main outcome measure

The primary outcome was pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score when pupils were 4 years older than at baseline.

Results

The primary outcome, pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score at follow-up 3, showed improvements for intervention arm pupils, compared with those in the control arm [relative risk -1.30 (95% confidence interval -1.87 to -0.73), standardised effect size -0.27 (95% confidence interval -0.39 to -0.15)]. There was no evidence of intervention effects according to deprivation: the results were significant for both affluent and deprived pupils. Subgroup analysis showed that all effect sizes were larger for the older cohort, particularly boys [relative risk -2.36 (95% confidence interval -3.62 to -1.11), standardised effect size -0.42 (95% confidence interval -0.64 to -0.20)]. Although there was no statistically significant difference in incremental cost and quality-adjusted life-years, the probability that the intervention is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year was high, at 88%. Particularly valued mechanisms of the SEED intervention were its provision of time to reflect on and discuss social and emotional well-being and its contribution to a culture of evaluating practice.

Limitations

It was a challenge to retain schools over five waves of data collection.

Conclusions

This trial demonstrated that the SEED intervention is an acceptable, cost-effective way to modestly improve pupil well-being and improve school climate, particularly for older boys and those with greater levels of psychological difficulties. It was beneficial during the transition from primary to secondary school, but this diminished after 6 years. The SEED intervention can be implemented alongside existing systems for addressing pupil well-being and can be complementary to other interventions.

Future work

Assess whether or not the SEED intervention has a beneficial impact on academic attainment, is transferable to other countries and other organisational settings, would be strengthened by adding core training elements to the intervention process and is transferable to secondary schools. Understand the gender differences illustrated by the outcomes of this trial. Conduct further statistical research on how to handle missing data in longitudinal studies of complex social interventions.

Trial registration

This trial is registered as ISRCTN51707384.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 10/3006/13) and is published in full in Public Health Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

School belonging mediates the association between negative school climate and depressive symptoms among Chinese adolescents: a national population-based longitudinal study

Background

A negative school climate is an important factor affecting students' mental health. However, few studies have focused on the mechanisms underlying the relationship. This study aimed to explore the mediating effect of school belonging on the association between negative school climate and depressive symptoms among Chinese adolescents, using a nationwide longitudinal survey.

Methods

We conducted a longitudinal study using data from the 2013 (T1) and 2014 (T2) waves of the China Education Panel Survey (CEPS). A negative school climate was assessed by school administrators' reports. School belonging and depressive symptoms were evaluated using adolescents' self-reports. We used a cross-lagged panel model to explore the mediating effect of school belonging on the association between negative school climate and depressive symptoms, adjusting for a set of covariates.

Results

In total, 7,049 Chinese adolescents with a mean age of 12.9 years were included in this study. The results of the cross-lagged model showed that negative school climate at T1 was significantly negatively associated with school belonging at T2 (β = -0.089, 95%CI = -0.111--0.067, p < 0.001), and was positively associated with depressive symptoms at T2 (β = 0.032, 95%CI = 0.012-0.054, p = 0.002). In addition, school belonging at T1 was significantly negatively associated with depressive symptoms at T2 (β = -0.025, 95%CI = -0.050--0.001, p = 0.045). Mediation analysis showed that school belonging played a mediating role in the association between negative school climate and depressive symptoms (β = 0.002, 95%CI = 0.001-0.005, p = 0.041).

Conclusion

Among Chinese adolescents, a negative school climate is associated with a greater risk of depressive symptoms. Improving school belonging may be helpful in decreasing the impact of a negative school climate on depressive symptoms in adolescents.

A protocol for a critical realist systematic synthesis of interventions to promote pupils' wellbeing by improving the school climate in low- and middle-income countries

INTRODUCTION

The review described in this protocol will be the first critical realist review of the literature reporting on the impact of interventions to promote pupils' wellbeing by improving the school climate in Low- and Middle-Income Countries. The review is being carried out to inform the programme theory for a critical realist evaluation of a whole school mindfulness intervention in Ethiopia and Rwanda to improve pupils' mental wellbeing. Our initial programme theory hypothesises that pupils' (and teachers') responses to the mindfulness intervention as well as changing the behaviour and attitudes of individual pupils and teachers, will change the 'school climate' in ways that have a positive impact on mental wellbeing. This literature review will facilitate the identification of mechanisms for change working at the level of the whole school climate, something which is only infrequently discussed in evaluations of mindfulness interventions.

METHODS AND ANALYSIS

A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school climate can promote the wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations and synthesising these to provide a conceptual understanding of the impact of interventions to improve school climate.

DISCUSSION

The review findings will inform a critical realist evaluation of a mindfulness intervention in schools that we will be carrying out. The findings from the review will enable us to focus more precisely and transparently on what policymakers and other stakeholders need to know about how school climate changes due to introducing mindfulness to the curriculum and how this impacts pupils' wellbeing [and for which pupils]. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media. PROSPERO registration number: CRD42023417735.

School-based interventions TO Prevent Dating and Relationship Violence and Gender-Based Violence: STOP-DRV-GBV systematic review

Background

Schools have a duty of care to prevent violence between students but a significant amount of dating and relationship violence and gender-based violence occurs in schools. These are important public health issues with important longitudinal consequences for young people.

Objectives

To understand functioning and effectiveness of school-based interventions for the prevention of dating and relationship violence and gender-based violence.

Review methods

We undertook a mixed-methods systematic review to synthesise different types of evidence relating to school-based interventions for the prevention of dating and relationship violence and gender-based violence to understand if, how and in what ways these interventions are effective. We searched 21 databases and 2 trial registers and undertook forwards and backwards citation chasing, author contact and other supplementary search methods. Searches identified all literature published to June 2021. All screening was undertaken in duplicate and independently, and we quality appraised all included studies.

Results

We included 247 reports (68 outcome evaluations, 137 process evaluations). Synthesis of intervention components produced an intervention typology: single-component, curricular, multicomponent, and multilevel programmes. Synthesis of intervention theories suggested that interventions aiming to increase students' sense of school belonging and sense of safety in the school building could encourage increased learning of prosocial skills and increased prosocial peer norms, and so potentially reducing dating and relationship violence and gender-based violence. Synthesis of factors affecting delivery highlighted school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important. Meta-analysis found stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration, and some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. Impacts on knowledge and attitudes were primarily short-term. Network meta-analysis did not suggest superiority of any intervention type. Moderation evidence suggested interventions reduced dating and relationship violence perpetration in boys more than girls, but reduced gender-based violence perpetration more in girls. Metaregression by intervention component did not explain heterogeneity in effectiveness, but qualitative comparative analysis suggested that reducing perpetration was important to reducing victimisation, and that perpetration could be reduced via focus on interpersonal skills, guided practice and (for gender-based violence) implementation of social structural components.

Limitations

Despite an exhaustive search, trials may have been missed and risk of publication bias was high for several analyses.

Conclusions

This is the most comprehensive systematic review of school-based interventions for dating and relationship violence and gender-based violence to date. It is clear that the prevention of dating and relationship violence and gender-based violence in schools will require longer-term investment to show benefit.

Future work

Future research is needed to understand why intervention effectiveness appears stronger for dating and relationship violence than gender-based violence.

Study registration

The study is registered as PROSPERO CRD42020190463.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR130144) and is published in full in Public Health Research; Vol. 12, No. 3. See the NIHR Funding and Awards website for further award information.

Whole-school interventions promoting student commitment to school to prevent substance use and violence, and improve educational attainment: a systematic review

Background

Whole-school interventions modify the school environment to promote health. A subset of these interventions promotes student commitment to school to prevent substance (tobacco, alcohol, other drugs) use and/or violence. A previous review identified the theory of human functioning and school organisation as a comprehensive theory of such interventions, and found evidence that these interventions reduce substance use and/or violence.

Objectives

The objectives were to search for, appraise and synthesise evidence to address the following questions: (1) What whole-school interventions promoting student commitment to school to prevent substance use and/or violence have been evaluated, what intervention subtypes are apparent and how closely do these align with the theory of human functioning and school organisation? (2) What factors relating to setting, population and intervention affect implementation? (3) What are the effects on student substance use, violence and educational attainment? (4) What is the cost-effectiveness of such interventions? (5) Are intervention effects mediated by student commitment to school or moderated by setting or population?

Data sources

A total of 56 information sources were searched (in January 2020), then an updated search of 48 of these was carried out (in May 2021). Reference lists were also searched and experts were contacted.

Review methods

Eligible studies were process/outcome evaluations of whole-school interventions to reduce student violence or substance use among students aged 5-18 years attending schools, via actions aligning with the theory of human functioning and school organisation: modifying teaching to increase engagement, enhancing student-staff relationships, revising school policies, encouraging volunteering or increasing parental involvement. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised qualitatively. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Searches retrieved 63 eligible reports on 27 studies of 22 interventions. We identified four intervention subtypes focused on student participation in school-wide decisions, improving staff-student relationships, increasing engagement in learning and involving parents. The theories of change of most intervention subtypes aligned closely with the theory of human functioning and school organisation, and informed refinement of an intervention theory of change. Theories of change for interventions increasing learning engagement did not align with this theory, aiming instead to increase school commitment primarily via social skills curricula. Factors influencing the implementation included whether or not interventions were tailorable, workable and well explained. Interventions with action groups comprising staff/students, etc. and providing local data were well implemented. Implementation was also affected by whether or not schools accepted the need for change and staff had the resources for delivery. Meta-analyses suggest small, but significant, intervention effects in preventing violence victimisation and perpetration, and substance use. There was sparse and inconsistent evidence of moderation and some evidence of mediation by student commitment to school. Two economic evaluations suggested that there is the potential for the interventions to be cost-effective.

Limitations

The quality of the studies was variable and the economic synthesis was limited to two studies.

Conclusions

Whole-school interventions aiming to promote student commitment to school share similar theories of change and factors affecting implementation. They have the potential to contribute to preventing violence and substance use among young people. Future trials should aim to optimise intervention effectiveness by better theorisation, and assess implementation and effect moderators and mediators.

Study registration

This study is registered as PROSPERO CRD42019154334.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/151/05) and is published in full in Public Health Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Oral health promotion through health-promoting schools in developing countries: A scoping review

OBJECTIVES

To explore and assess what is known about oral health promotion through health-promoting primary schools in developing countries.

METHODS

A scoping review was conducted using the Arksey & O'Malley framework. Web of Science, PubMed, Scopus and Cochrane Library were searched, followed by the reference lists of the resulting studies. The UN classification of developing countries was used to define the countries included and the search was between 1986 and 2021. Quality assessment was carried out using Joanna Briggs Institute's quality appraisal tools.

RESULTS

The search resulted in 33 studies of which almost half were randomized controlled trials. The oral health promotion strategies were oral health education (n = 16) delivered by teachers, parents or peers, or multicomponent involving both toothbrushing (n = 15) and dietary components (n = 2). Most of the included studies were conducted in Asia (n = 25/33).

CONCLUSIONS

Findings suggested that comprehensive, multicomponent theory-based oral health promotion showed improvements in oral health outcomes of schoolchildren, particularly if delivered using a whole-school approach. However, further research on feasibility and implementation of oral health promotion through health-promoting primary schools in developing countries should be considered.

Effects of school indoor visual environment on children's health outcomes: A systematic review

Children's visual perceptions are critical for their comfort and health. This review explores the impacts of school indoor visual environment on children's health outcomes. A systematic search yielded 5704 articles, of which 32 studies were reviewed. Five environmental themes were identified: lighting, access to nature, window characteristics, art/environmental aesthetics, and ergonomics/spatial arrangement. Results affirm that visual environment affects children's health. There are disparities across environmental themes, with more extensive evidence for lighting and access to nature, but relatively limited in other areas. This study suggests a need for multi-disciplinary collaboration to develop a holistic perspective.

Whole-school interventions promoting student commitment to school to prevent substance use and violence: a systematic review

OBJECTIVES

Whole-school interventions that promote student commitment to school are a promising modality to reduce health inequalities through school-level change; however, evidence for the effectiveness of these interventions in improving policy-relevant health outcomes, such as substance use and violence, has not been comprehensively synthesised.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

We searched 20 databases and a range of other sources to identify randomised trials meeting our intervention definition and reporting substance use and violence outcomes. Extracted effect estimates were meta-analysed using robust variance estimation with random effects, separating effects <1 year from baseline and effects at or more than 1 year from baseline.

RESULTS

We included 18 evaluations with varying risk of bias. Pooled effects suggested significant impacts on short-term (odds ratio [OR] = 0.85, 95% confidence interval [CI] 0.76, 0.96) and long-term (OR = 0.79, 95% CI 0.65, 0.98) violence perpetration, short-term (OR = 0.84, 95% CI 0.72, 0.98) and long-term (OR = 0.85, 95% CI 0.73, 0.99) violence victimisation, and short-term (OR = 0.83, 95% CI 0.70, 0.97) and long-term (OR = 0.79, 95% CI 0.62, 0.998) substance use outcomes, with effects relatively stable between short-term and long-term analyses. Stratifying substance use meta-analyses by type (e.g. smoking, alcohol) did not impact results. All meta-analyses had substantial heterogeneity.

CONCLUSION

Although diverse in content, interventions appear effective with respect to the review outcomes and as a form of universal prevention. Future research should consider contextual contingencies in intervention effectiveness, given considerable policy and practice interest in these interventions and the need to support schools in effective decision-making as to intervention choice.

Integration of evidence into Theory of Change frameworks in the healthcare sector: A rapid systematic review

BACKGROUND

Theory of Change (ToC) has become an established approach to design and evaluate interventions. While ToC should-in line with the growing international focus on evidence-informed health decision-making-consider explicit approaches to incorporate evidence, there is limited guidance on how this should be done. This rapid review aims to identify and synthesize the available literature on how to systematically use research evidence when developing or adapting ToCs in the health sector.

METHODS

A rapid review methodology using a systematic approach, was designed. Eight electronic databases were consulted to search for peer-reviewed and gray publications detailing tools, methods, and recommendations promoting the systematic integration of research evidence in ToCs. The included studies were compared, and the findings summarized qualitatively into themes to identify key principles, stages, and procedures, guiding the systematic integration of research evidence when developing or revising a ToC.

RESULTS

This review included 18 studies. The main sources from which evidence was retrieved in the ToC development process were institutional data, literature searches, and stakeholder consultation. There was a variety of ways of finding and using evidence in ToC. Firstly, the review provided an overview of existing definitions of ToC, methods applied in ToC development and the related ToC stages. Secondly, a typology of 7 stages relevant for evidence integration into ToCs was developed, outlining the types of evidence and research methods the included studies applied for each of the proposed stages.

CONCLUSION

This rapid review adds to the existing literature in two ways. First, it provides an up-to-date and comprehensive review of the existing methods for incorporating evidence into ToC development in the health sector. Second, it offers a new typology guiding any future endeavors of incorporating evidence into ToCs.

Educators' perceptions of e-cigarettes in Australian secondary schools

INTRODUCTION

Secondary schools are a setting in which e-cigarette use among students has increased significantly, resulting in an urgent need for educators to develop and implement strategies to curb youth vaping. Research assessing school-based vaping prevention efforts is limited and largely confined to the US. This study assessed Australian secondary school staff members' experiences with e-cigarettes and explored (i) the presence of e-cigarette policies and educational programs, (ii) barriers to policy development and implementation, and (iii) desired support.

METHODS

Public, Catholic, and Independent secondary schools across Australia were sent an invitation to participate in this study, which involved completion of an online survey. A total of 218 school staff members (55% women) participated. Respondents included school principals, teachers, and other staff members. Data collection occurred May to September 2022. Both quantitative and qualitative data were collected.

RESULTS

Nearly half (46%) of all school staff members surveyed reported finding a student with an e-cigarette on campus at least monthly, and one-third (36%) of principals reported suspending or expelling students at least monthly for e-cigarette possession or use. The vast majority of those surveyed agreed that e-cigarette use is increasingly becoming a problem in secondary schools (93%) and reported being concerned about e-cigarette use by students (94%). Only half (51%) reported that their school had an e-cigarette policy in place. The discreet appearance of e-cigarettes (83%) and difficulties pinpointing from where the vapor/scent is coming (73%) were the most frequently reported barriers to policy enforcement.

CONCLUSIONS

The results of this study suggest that e-cigarettes present a threat to secondary school environments. There is an urgent need to develop, implement, and enforce both school- and government-level e-cigarette policies to prevent and reduce youth vaping in Australian secondary schools.

School-based interventions for preventing dating and relationship violence and gender-based violence: A systematic review and synthesis of theories of change

School-based interventions for preventing dating and relationship violence (DRV) and gender-based violence (GBV) are an important way of attempting to prevent and reduce the significant amount of DRV and GBV that occurs in schools. A theoretical understanding of how these interventions are likely to cause change is essential for developing and evaluating effectiveness, so developing an overarching theory of change for school-based interventions to prevent DRV and GBV was the first step in our systematic review. Theoretical data were synthesised from 68 outcome evaluations using methods common to qualitative synthesis. Specifically, we used a meta-ethnographic approach to develop a line-of-argument for an overarching theory of change and Markham and Aveyard's (2003, Social Science & Medicine, 56, 1209) theory of human functioning and school organisation as a framework for structuring the concepts. The overall theory of change generated was that by strengthening relationships between and among staff and students, between the classroom and the wider school, and between schools and communities, and by increasing students' sense of belonging with student-centred learning opportunities, schools would encourage student commitment to the school and its values, prosocial behaviour and avoidance of violence and aggression. The theory of human functioning informed our understanding of the mechanisms of action but from our analysis we found that it required refinement to address the importance of context and student agency.

What factors influence implementation of whole-school interventions aiming to promote student commitment to school to prevent substance use and violence? Systematic review and synthesis of process evaluations

BACKGROUND

Whole-school interventions go beyond classroom health education to modify the school environment to promote health. A sub-set aim to promote student commitment to school to reduce substance use and violence (outcomes associated with low commitment). It is unclear what factors influence implementation of such interventions.

METHODS

We conducted a systematic review including synthesis of evidence from process evaluations examining what factors affect implementation. Meta-ethnographic synthesis was informed by May's General Theory of Implementation.

RESULTS

Sixteen reports, covering 13 studies and 10 interventions were included in our synthesis. In terms of May's concept of 'sense-making', we found that school staff were more likely to understand what was required in implementing an intervention when provided with good-quality materials and support. Staff could sometimes wilfully or unintentionally misinterpret interventions. In terms of May's concept of 'cognitive participation', whereby staff commit to implementation, we found that lack of intervention adaptability could in particular undermine implementation of whole-school elements. Interventions providing local data were reported as helping build staff commitment. School leaders were more likely to commit to an intervention addressing an issue they already intended to tackle. Collaborative planning groups were reported as useful in ensuring staff 'collective action' (May's term for working together) to enact interventions. Collective action was also promoted by the presence of sufficient time, leadership and relationships. Implementation of whole-school interventions took time to build. Considering May's concept of 'reflexive monitoring' (formal or informal review of progress), this was important in assessing and enhancing implementation. 'Quick wins' could help maintain collective impetus to implement further intervention activities.

CONCLUSION

We identified novel factors influencing implementation of whole-school elements such as: local adaptability of interventions; providing local data to build commitment; interventions addressing an issue already on school leaders' agenda; collaborative planning groups; and 'reflexive monitoring' as an explicit intervention component.

A Systematic Review of School Transition Interventions to Improve Mental Health and Wellbeing Outcomes in Children and Young People

Normative transitions between educational settings can be important life events for young people, having the potential to influence mental health trajectories across the life course. Interventions to target transitions have been used to support children and young people as they transition between school settings, but there is limited synthesis of their effects. Seven databases were searched to identify studies of universal interventions focused on supporting mental health and wellbeing across three main types of educational transition: preschool to elementary school; school to school (including elementary to middle; middle to high and other combinations depending on country); and high school to post-compulsory education. Effect directions for behavioural, psychological/emotional and social measures of mental health were extracted for each study and synthesized using effect direction plot methodology. Searches identified 6494 records for screening. This resulted in 34 papers being included in the review, consisting of 24 different interventions. Social outcomes appeared more amenable to intervention than behavioural outcomes, with mixed findings for psychological measures of mental health. Intervention characteristics shifted based on the age of young person involved in the transition, with greater focus on parenting and school environment during the early transitions, and more focus on social support for the transition to post-compulsory education. A broad range of interventions were identified for supporting mental health and wellbeing across the three types of educational transition with mixed impact and diverse methodologies. More research is needed to identify transferable intervention mechanisms that may hold across different contexts and settings. PROSPERO registration number: CRD42020176336.

School culture and student mental health: a qualitative study in UK secondary schools

Background

There is consistency of evidence on the link between school culture and student health. A positive school culture has been associated with positive child and youth development, effective risk prevention and health promotion efforts, with extensive evidence for the impact on student mental health. Interventions which focus on socio-cultural elements of school life, and which involve students actively in the process, are increasingly understood to be important for student mental health promotion. This qualitative study was undertaken in three UK secondary schools prior to the implementation of a participative action research study bringing students and staff together to identify changes to school culture that might impact student mental health. The aim was to identify how school culture is conceptualised by students, parents and staff in three UK secondary schools. A secondary aim was to explore which components of school culture were perceived to be most important for student mental health.

Methods

Across three schools, 27 staff and seven parents participated in in-depth interviews, and 28 students participated in four focus groups. The Framework Method of thematic analysis was applied.

Results

Respondents identified elements of school culture that aligned into four dimensions; structure and context, organisational and academic, community, and safety and support. There was strong evidence of the interdependence of the four dimensions in shaping the culture of a school.

Conclusions

School staff who seek to shape and improve school culture as a means of promoting student mental health may have better results if this interdependence is acknowledged, and improvements are addressed across all four dimensions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13034-x.

Is positive school climate associated with better adolescent mental health? Longitudinal study of young people in England

Background and objectives

Studies suggest that individual student-reported connection to school is associated with better mental health. However, there is less evidence for associations between schools’ overall school climate and the mental health of their students. This may reflect limitations in which mental health outcomes have been examined. We conducted a large longitudinal study in schools, hypothesising that we would find associations at both the student and school levels between student-reported positive school climate, and reduced student conduct and emotional problems and improved mental wellbeing.

Methods

We tracked students in 20 English secondary schools from near the end of the first year of secondary school (age 11/12) over 3 years using reliable measures of school climate and mental health.

Results

We found associations between student-level reports of positive school climate at baseline, and reduced conduct and emotional problems and better mental wellbeing at 3-year follow-up adjusting for various potential confounders. We also found some evidence of adjusted associations between baseline school-level measures of overall positive climate and better student mental health at follow-up. However, these student- and school-level associations reduced considerably when also adjusting for baseline mental health.

Conclusions

Our findings suggest that there are associations between school climate and student mental health at both the student and school level but these associations are complex and not necessarily causal.

•

Previous studies provide little evidence that mental health differ between schools or is influenced by school climate.

•

These studies' ability to identify school effects may have been undermined by choice of outcomes.

•

Our study suggests that mental health may be better in schools with more student belonging.

Adolescents' Concerns About School Violence or Shootings and Association With Depressive, Anxiety, and Panic Symptoms

IMPORTANCE

The prevalence of internalizing problems among US adolescents has risen in the past decade. The extent to which concerns about school violence or shootings are associated with risk of internalizing problems is unknown.

OBJECTIVE

To examine the prospective association of concern, worry, and stress related to school violence or shootings with internalizing problems and to examine sex and racial and ethnic differences in the magnitude of the associations.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study involved 3 surveys administered 6 months apart (fall of grade 11 [prebaseline]; spring of grade 11 [baseline]; and fall of grade 12 [follow-up]) from 2015 to 2016. Participants included 2263 students from 10 high schools in Los Angeles, California. Analyses were performed from April 29, 2020, to April 8, 2021.

EXPOSURES

Baseline self-reported level of concern, worry, and stress about shootings or violence at the student's school or other schools, each rated on 5-point scales (ranging from not at all [0] to extremely [4]) with a mean score calculated as a 3-item composite index rescaled into z-score standard deviation units.

MAIN OUTCOMES AND MEASURES

Surpassing clinically significant or borderline significant thresholds for major depressive disorder, generalized anxiety disorder, or panic disorder based on symptom ratings on the Revised Children's Anxiety and Depression Scale at 6-month follow-up.

RESULTS

Of the 2263 students included in the analyses (1250 [55.2%] girls; mean [SD] age, 16.5 [0.4] years), appreciable proportions reported being very or extremely concerned (850 0f 2226 [38.2%]), worried (703 of 2209 [31.8%]), or stressed (332 of 2183 [15.2%]) about shootings or violence at their school or other schools. After adjusting for prebaseline covariates, concerns about school violence or shootings were associated with clinically significant generalized anxiety symptoms (odds ratio [OR], 1.31; 95% CI, 1.15-1.50) and panic symptoms (OR, 1.18; 95% CI, 1.05-1.32), but not depressive symptoms (OR, 1.13; 95% CI, 0.99-1.30) at the 6-month follow-up. There was a significant association between concern with school violence or shootings and depressive symptoms for Black youth (OR, 3.15; 95% CI, 1.38-7.19) and non-Hispanic/Latinx White youth (OR, 1.62 [95% CI, 1.25-2.09]) but not for youth of other races and ethnicities (OR for Asian, 1.26 [95% CI, 0.86-1.85]; OR for Hispanic/Latinx, 0.94 [95% CI, 0.76-1.16]; OR for other, 0.93 [95% CI, 0.54-1.61]). Sex did not moderate these associations.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that concern, worry, and stress related to school violence or shootings may be risk factors for internalizing problems among adolescents, with variation in the strength of the association by race/ethnicity.

Intervention impact on alcohol use, alcohol harms, and a combination of both: A latent class, secondary analysis of results from a randomized controlled trial

BACKGROUND

Alcohol use and alcohol-related harm (ARH) among adolescents places a substantial burden on health, and public services more generally. To date, attempts to intervene at a universal level have yielded results varying from iatrogenic to null, although some skill-enhancing universal interventions have successfully impacted drinking behaviors. One such intervention is SHAHRP. The present study is a secondary analysis of data from the STAMPP Trial, providing new, and more nuanced findings.

METHODS

A total of 13,914 adolescents (41.7% female) participated in this cRCT where schools were randomly assigned to a control or intervention group. Growth mixture modelling was used to identify trajectory classes from baseline through third follow-up (+33 months) of adolescents on heavy episodic drinking (HED) and ARH. Extracted classes were related to school intervention participation using multinomial logistic regression.

RESULTS

Five trajectory classes of the HED and ARH composite were identified: Low (62%), Late Onset (16%), Early Onset (13%), Delayed Onset (7%), and Unstable (3%). The intervention was most strongly related to Late Onset (OR = 0.50, 95%CI [0.25, 1.01]) and Delayed Onset (OR = 0.55, 95%CI [0.26, 1.16]), although not statistically significant. With classes constructed with ARH only, the Delayed Onset class was significantly related to the intervention (OR = 0.60, 95%CI [0.43, 0.84]).

CONCLUSIONS

These results support those previously reported on the STAMPP Trial and provide a more nuanced insight into the effects of the intervention.

Theories of self-care and self-management of long-term conditions by community-dwelling older adults: A systematic review and meta-ethnography

RATIONALE

The proportion of older adults living with long-term conditions (LTCs) is increasing. Self-care and self-management approaches are seen as valuable in helping older people with LTCs to manage their health and care, yet the theoretical overlaps and divergences are not always clear.

OBJECTIVES

The objectives of this review were to: (1) systematically identify and appraise studies of self-care or self-management of LTCs by community-dwelling older adults (aged ≥60 years) either informed by, applying, creating, or testing theory; (2) explore similarities or points of convergence between the identified theories; and (3) use a meta-ethnographic approach to synthesise the theories and group related concepts into core constructs.

METHODS

We conducted a systematic theory synthesis, searching six electronic databases. Three reviewers independently screened titles and abstracts followed by full texts and two reviewers appraised study quality. Theoretical data were synthesised within and across individual theories using meta-ethnographic line-of-argument synthesis.

RESULTS

A total of 141 articles (138 studies) and 76 theories were included in the review. Seven core constructs were developed: (1) temporal and spatial context; (2) stressors; (3) personal resources; (4) informal social resources; (5) formal social resources; (6) behavioural adaptations; and (7) quality of life outcomes. A line of argument was developed that conceptualised older adults' self-care and self-management as a dynamic process of behavioural adaptation, enabled by personal resources and informal and formal social resources, aimed at alleviating the impacts of stressors and maintaining quality of life.

CONCLUSION

This synthesis provides an overview of theories used in research on older adults' LTC self-care and self-management. Our synthesis describes the complex interplay of intrinsic and extrinsic factors influencing self-care and self-management behaviours and provides considerations for future research, intervention design, and implementation. The utility of the constructs in research and practice requires further attention and empirical validation.

Positioning zoonotic disease research in forced migration: A systematic literature review of theoretical frameworks and approaches

BACKGROUND

The emergence and transmission of zoonotic diseases are driven by complex interactions between health, environmental, and socio-political systems. Human movement is considered a significant and increasing factor in these processes, yet forced migration remains an understudied area of zoonotic research-due in part to the complexity of conducting interdisciplinary research in these settings.

OBJECTIVES

We conducted a systematic review to identify and analyze theoretical frameworks and approaches used to study linkages between forced migration and zoonotic diseases.

METHODS

We searched within eight electronic databases: ProQuest, SCOPUS, Web of Science, PubMed, PLoSOne, Science Direct, JSTOR, and Google Scholar, to identify a) research articles focusing on zoonoses considering forced migrants in their study populations, and b) forced migration literature which engaged with zoonotic disease. Both authors conducted a full-text review, evaluating the quality of literature reviews and primary data using the Critical Appraisal Skills Programme (CASP) model, while theoretical papers were evaluated for quality using a theory synthesis adapted from Bonell et al. (2013). Qualitative data were synthesized thematically according to the method suggested by Noblit and Hare (1988).

RESULTS

Analyses of the 23 included articles showed the increasing use of interdisciplinary frameworks and approaches over time, the majority of which stemmed from political ecology. Approaches such as EcoHealth and One Health were increasingly popular, but were more often linked to program implementation and development than broader contextual research. The majority of research failed to acknowledge the heterogeneity of migrant populations, lacked contextual depth, and insufficient acknowledgments of migrant agency in responding to zoonotic threats.

CONCLUSIONS

Addressing the emergence and spread of zoonoses in forced migration contexts requires more careful consideration and use of interdisciplinary research to integrate the contributions of social and natural science approaches. Robust interdisciplinary theoretical frameworks are an important step for better understanding the complex health, environment, and socio-political drivers of zoonotic diseases in forced migration. Lessons can be learned from the application of these approaches in other hard-to-reach or seldom-heard populations.

How do we harness adolescent values in designing health behaviour change interventions? A qualitative study

OBJECTIVES

Adolescent health behaviours do not support optimal development. Adolescents are reportedly difficult to engage in health behaviour improvement initiatives. Little is known about what adolescents value in relation to diet and physical activity or how best to target these in health interventions. This study explored adolescents' values in relation to diet and physical activity and how these values can inform health intervention design.

DESIGN

Qualitative semi-structured interviews explored adolescents' lives, what they thought about diet and physical activity and what might support them to improve their health behaviours.

METHODS

A total of 13 group interviews were conducted with 54 adolescents aged 13-14 years, of whom 49% were girls and 95% identified as White British. Participants were recruited from a non-selective secondary school in a large southern UK city. Inductive thematic analysis was used to identify key adolescent values.

RESULTS

Adolescents valued being with their friends, doing what they enjoyed and were good at; being healthy was important to them but only if achievable without compromising other things that are important to them. The need to be healthy was not aligned with adolescents' basic psychological needs, nor their strongly held priorities and values.

CONCLUSIONS

Health is not a motivating factor for adolescents; therefore, interventions designed solely to improve health are unlikely to engage them. Instead, interventions that align with the values and priorities specified by adolescents are more likely to be effective in supporting them to eat well and be more active.

The Association Between Smoke-Free School Policies and Adolescents' Perceived Antismoking Norms: Moderation by School Connectedness

Introduction

Many European schools implement smoke-free school policies (SFSPs). SFSPs may decrease adolescent smoking by causing adolescents to perceive stronger antismoking norms, yet there exists no quantitative evidence that indicates for which norms and for whom such effects may occur. This study therefore assessed to what extent adolescents’ perceived antismoking norms among best friends, teachers, and society at large were associated with SFSPs, and whether these associations were moderated by adolescents’ level of school connectedness.

Aims and Methods

Survey data were collected in 2016/2017 on 10,653 adolescents aged 14–16 years old and 315 staff members in 55 schools from seven European cities. Associations of adolescent-perceived SFSPs and staff-reported SFSPs with best friend, teacher, and societal antismoking norms were estimated in multilevel logistic regression models, adjusted for demographics and school-level smoking prevalence. We tested for interaction between school connectedness and SFSPs.

Results

Adolescent-perceived SFSPs were positively associated with antismoking norms by teachers (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.15–1.85), were negatively associated with antismoking norms by best friends (OR: 0.81, 95% CI: 0.67–0.99), but were not significantly associated with antismoking norms by society at large (OR: 0.87, 95% CI: 0.74–1.02). All interaction tests between adolescent-perceived SFSPs and school connectedness were nonsignificant. Staff-reported SFSPs were not associated with any norm and showed no significant interaction with school connectedness.

Conclusions

We found that SFSPs are associated with adolescents’ perception of more antismoking norms by teachers, but less antismoking norms by best friends, irrespective of adolescents’ level of school connectedness.

Implications

Smoke-free school policies, just as many other tobacco control policies, are assumed to foster adolescents’ perception of antismoking norms. Still, current evidence does not demonstrate which antismoking norms may be influenced by SFSPs and whether this influence is equal for adolescents with different levels of school connectedness. This study suggests that SFSPs foster adolescents’ perception of antismoking norms by teachers, but may concurrently lead to the perception of less antismoking norms by best friends, irrespective of adolescents’ school connectedness. SFSPs may therefore need to be complemented with interventions that target antismoking norms in adolescent peer groups.

Understanding further education as a context for public health intervention: qualitative findings from a study process evaluation

BACKGROUND

Over 1.2 million 16-18 year-olds are enrolled in further education (FE-advanced secondary education) in England. Life course transitions provide opportunities to change, establish or reinforce health behaviours. FE presents an opportunity for public health improvement, yet few interventions target this setting. Using a smoking prevention intervention, we explore how young people were viewed in FE and how this affected intervention acceptability.

METHODS

Eleven student and five staff focus groups were conducted in three intervention institutions (two colleges, one school sixth-form), as part of the process evaluation of a smoking prevention feasibility study. FE managers in intervention and control institutions were also interviewed (n = 5). Data were analysed using thematic analysis.

RESULTS

In both colleges and the sixth-form, students were viewed as emergent adults and treated differently from 'school-children', in practice if not in policy. Colleges permitted smoking in designated areas; in the school sixth-form smoking was unofficially tolerated but concealed from younger students. Using staff to deliver anti-smoking messages reintroduced an unwanted power dynamic which disrupted perceptions of students as young adults.

CONCLUSIONS

FE is an important setting for young people's health. Understanding the culture and context of FE is critical in designing acceptable and effective public health interventions.

School-Based Tobacco Control and Smoking in Adolescents: Evidence from Multilevel Analyses

Since 2015, universal comprehensive school-based tobacco control programs have been provided in all primary and secondary schools in Korea. This study explored the association of school-level tobacco control with adolescent smoking, and the interactions to investigate whether gender moderates the impact of school tobacco control programs and school-level norms. Both school- and individual-level data were drawn from the 2015 School-Based Tobacco Prevention Program Survey. Multilevel logistic regression analyses were performed using data from 4631 students (ages 10-18 years) who were nested in 62 secondary schools in Seoul, Korea. Students who participated in more prevention programs were less likely to smoke (OR = 0.47, 95% CI 0.30-0.74). The effect of the programs was significantly moderated by gender. For boys, exposure to a greater number of programs decreased the risk of smoking (OR = 0.32, 95% CI 0.18-0.57) but not for girls. At the school level, the school norm regarding tobacco control regulations was negatively associated with smoking (OR = 0.28, 95% CI 0.11-0.76), and its effect was significant for girls only (OR = 0.35, 95% CI 0.17-0.76). This study highlights how the school environment is associated with adolescent smoking behavior, and the effects of programs and norms are different by gender. The findings suggest the need to develop strategies to enhance school-based tobacco control programs and the school norm considering gender differences.

The impact of the World Health Organization Health Promoting Schools framework approach on diet and physical activity behaviours of adolescents in secondary schools: a systematic review

OBJECTIVE

To examine the effectiveness of interventions using the World Health Organization Health Promoting Schools (HPSs) framework approach in increasing physical activity (PA) and improving the diet of 11-18-year-olds.

STUDY DESIGN

A systematic review guided by the National Health Services Centre for Reviews and Dissemination framework and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses.

METHODS

Nine databases and trial registries were searched from 2013 to 2018 for cluster randomised controlled trials involving adolescents' aged 11-18 years. We also included relevant studies from a 2014 Cochrane Review of HPS approach on health behaviours. Data were extracted from included studies and assessed for quality.

RESULTS

Twelve eligible studies were identified from seven countries. The studies varied in outcome measures, sample size, quality and duration of intervention and follow-up. Only four of the included studies were of high to moderate quality. We found some evidence of effectiveness for physical activity only interventions and limited evidence of effectiveness for nutrition only and combined PA and nutrition interventions.

CONCLUSIONS

There were no discernible patterns across the studies to suggest effective mechanisms for the HPS approach. The family/community component was poorly developed and superficially reported in all studies. Future research should seek to understand how best to work in partnership with secondary schools, to foster and sustain a healthy eating and physical activity culture, which aligns with their core aims. More attention should be paid to the restriction of unhealthy foods in the school environment.

Analysis of whole-school policy changes in Austrian schools

Health Policies with school-wide effects have been shown to improve the health of students and school staff, but in practice, schools struggle with this approach. Ten Austrian schools which had recently adopted new time structure policies were investigated: On the basis of 19 interviews with school staff, we used thematic analysis to identify facilitating and hindering factors for the implementation processes. Furthermore, agency analysis was applied, in which the interviewees’ use of language was interpreted to estimate their perception of their own agency in the context of policy change. We found that in schools where policy changes were perceived as successfully implemented, staff was convinced of the benefits. In these schools, time structures were understood to directly influence learning and teaching processes and staff members showed a strong feeling of agency. On the other hand, schools were confronted with hindering factors similar to those known from the implementation of other health policies. The results are discussed in the light of current implementation practices, and conclusions for practitioners are drawn.

School-level factors associated with teacher connectedness: a multilevel analysis of the structural and relational school determinants of young people's health

Background

Conducting research on the antecedents of teacher connectedness (TC) is key to inform intervention and policy that can leverage the public health potential of teachers for young people’s well-being. As part of the EU-funded Teacher Connectedness Project, this study aims to examine the contribution of a variety of school-level factors (including type of school, school size, student–teacher ratio, students per class and teacher gender).

Methods

Sample consisted of 5335 adolescents aged 11, 13 and 15 years that had participated in the HBSC study in England. Multilevel multinomial regression was used to examine the contributions of sociodemographic and school-level factors to TC.

Results

TC was lower in older adolescents and those from less affluent families, but similar in boys and girls. Regarding school-level factors, it was not the size of the school but the ratio of students per teacher which was significantly associated to TC, with higher student–teacher ratio being significantly associated with lower odds of medium-to-high TC. Some differences between mixed and all-girls schools were also found.

Conclusions

Health promotion strategies targeting student–teacher relationships need to consider how TC changes by age and SES and give attention to school-level factors, in particular the student–teacher ratio.

Alcohol Expectancies Moderate the Association Between School Connectedness and Alcohol Consumption

BACKGROUND

In this study, we investigate the moderated association of school connectedness and alcohol expectancies with adolescent drinking.

METHODS

Two large community samples were obtained with 2 repeated attempted censuses of all students attending a large suburban school district. Participants completed a self-administered questionnaire that assessed substance use, alcohol expectancies, and school connectedness. We used logistic regression analyses on the training sample and confirmed with Bayesian test intervals with the test sample.

RESULTS

Party related alcohol expectancies and school connectedness interacted in their explanatory association with recent drinking and binging, such that school connectedness had a protective association only for youth with lower positive expectancies. These findings were the result of pre-planned exploratory analysis, which were confirmed with out-of-sample test data.

CONCLUSIONS

The potential benefits for student health behaviors resulting from improved school connectedness may be dependent on at least one dimension of alcohol expectancies, at the individual level.

Interventions integrating health and academic education in schools to prevent substance misuse and violence: a systematic review

Background

Schools struggle to timetable health education. Interventions integrating academic and health education to reduce substance use and violence offer promise. No current systematic reviews examine such interventions.

Objectives

To review evidence to explore the following questions: (1) what types of interventions integrating health and academic education in schools serving those aged 4–18 years have been evaluated? (2) What theories of change inform these interventions? (3) What factors facilitate or limit the successful implementation and receipt of such interventions, and what are the implications for the delivery of such implementations in the UK? (4) How effective are such interventions in reducing smoking and violence and the use of alcohol and drugs, and at increasing attainment? Does this vary by students’ sociodemographic characteristics? (5) What factors appear to influence the effectiveness of such interventions?

Data sources

In total, 19 databases were searched from 18 November to 22 December 2015, updating searches for outcome evaluations for violence on 28 February 2018 and for substance use on 14 May 2018. References were extracted from included studies and authors contacted.

Review methods

Included studies reported on theories of change, and process or outcome evaluations of interventions that integrated academic and health education to reduce substance use and/or violence. References were screened on the title/abstract and then on the full report. Data extraction and appraisal used Cochrane, Evidence for Policy and Practice Information Centre and other established tools. Theories of change and process data were qualitatively synthesised. Outcome evaluations were synthesised narratively and meta-analytically.

Results

In total, 78,451 unique references were originally identified and 62 reports included. Search updates on 28 February and 14 May 2018 retrieved a further 2355 and 1945 references, respectively, resulting in the inclusion of six additional reports. Thirty-nine reports described theories, 16 reports (15 studies) evaluated process and 41 reports (16 studies) evaluated outcomes. Multicomponent interventions are theorised to erode ‘boundaries’ (strengthen relationships) between academic and health education, teachers and students, behaviour in classrooms and in the wider school, and schools and families. Teachers, pro-social peers and parents are theorised to act as role models and reinforcers of healthy behaviours learnt in lessons. There was clear evidence that interventions are facilitated by supportive senior management and alignment with the schools’ ethos, collaborative and supportive teaching environments, and positive pre-existing student, teacher and parent attitudes towards interventions. The barriers were overburdened teachers who had little time to both learn and implement integrated curricula. The strongest evidence for effectiveness was found for the reduction of substance use in school key stages (KSs) 2 and 3. For example, a meta-analysis for substance use at KS3 reported a mean difference of –0.09 (95% confidence interval –0.17 to –0.01). A meta-analysis for effectiveness in reducing violence victimisation in KS2 found no effect. There was mixed evidence for effects on academic outcomes, with meta-analysis precluded by methodological heterogeneity.

Limitations

Study quality was variable. Integration was sometimes not emphasised in theories of change.

Conclusions

These interventions are undertheorised but involve multiple forms of boundary erosion. There is clear evidence of characteristics affecting implementation. Interventions are likely to have the greatest impact on substance use. These programmes may be effective in reducing substance use but do not appear to reduce violence and findings on educational impacts are mixed.

Future work

Future evaluations should assess interventions with clearer theories of change and examine academic outcomes alongside violence and substance use outcomes.

Study registration

This study is registered as PROSPERO CRD42015026464.

Funding

The National Institute for Health Research Public Health Research programme.

Associations of school tobacco policies and legislation with youth smoking: a cross-sectional study of Danish vocational high schools

BACKGROUND

In vocational high schools, the prevalence of smoking is high (nearly 40% daily smoking in Danish vocational high schools). Schools are increasingly adopting school tobacco policies (STPs) and a national law on smoke-free school grounds has been implemented. Our objective was to explore the extent of STPs in vocational schools and examine the association of STPs and smoke-free school grounds legislation with student smoking.

METHODS

We used data from the cross-sectional Danish National Youth Study 2014, including 5013 vocational high school students (76% male) at 40 campuses. Implementation of STPs was measured by questionnaires to principals and field observations of smoking practices were conducted. Logistic regression models assessed whether STP characteristics were associated with students' current smoking (ie, daily and occasional) compared with non-current smoking. Negative binominal regression models assessed cigarettes per day among daily smokers.

RESULTS

Schools covered by the national law on smoke-free school ground had more comprehensive STPs than schools not covered by the law. Student smoking was observed on 78% of campuses, with less visibility of smoking in schools covered by the national law (69% vs 83%). Current smoking was lower for students attending a school covered by the national law (OR=0.86, 95% CI 0.75 to 0.97). Students who attended schools that allowed teacher-student smoking were more likely to smoke (OR=1.13, 95% CI 1.01 to 1.27).

CONCLUSIONS

A law on smoke-free school grounds was associated with less current smoking in vocational high schools, while school norms that are supportive of teacher-student smoking were associated with greater odds of current smoking. Visibility of student smoking was less prevalent at schools covered by the law on smoke-free school grounds; nevertheless, the visibility of smoking was high. Better enforcement or an extension of the current law on smoke-free school grounds is recommended.

Effects of Interventions Addressing School Environments or Educational Assets on Adolescent Sexual Health: Systematic Review and Meta-analysis

CONTEXT

School-based interventions that aim to modify sexual health knowledge, attitudes and behaviors have mixed and often unsustained effects on adolescent sexual health outcomes. However, observational evidence suggests that broader school-related factors, such as school climate and academic attainment, can influence outcomes.

METHODS

Nine databases were searched in July 2017 for randomized and quasi-experimental evaluations of interventions addressing school-level environment or student-level educational assets, to examine whether such interventions can promote young people's sexual health. Searches were limited to studies published since 1990 but were not restricted by language. Studies were assessed for risk of bias and synthesized narratively and meta-analytically.

RESULTS

Searches yielded 11 evaluations, published from 1999 to 2016, of interventions related to school-level environment or student-level educational assets. Because of inconsistent reporting, the risk of bias was not clear for most studies, and meta-analysis was possible for only one outcome. The meta-analysis of three randomized trials provided some evidence that school-environment interventions may delay sexual debut (pooled odds ratio, 0.5). Narrative synthesis of the remaining outcomes found mixed results, but suggests that interventions addressing school-level environment may delay sexual debut and that those addressing student-level educational assets may reduce risk of pregnancy and STDs.

CONCLUSIONS

Additional and more rigorous evidence is needed to assess the probability that interventions addressing school-related factors are effective and to provide better understanding of the mechanisms by which they may work to improve adolescent sexual health.

A translational approach to characterization and measurement of health-promoting school ethos

A health promoting schools (HPS) approach is hypothesized to influence student health and wellbeing by promoting a 'school ethos' that reflects the physical environment, social relations, organisational structure, policies and practices within schools. This complex set of factors makes health promoting school ethos (HPSE) challenging to define and measure. This work sought to theorise, develop and pilot a measure of HPSE as the context for implementation of HPS initiatives. We used a multi-method, iterative process to identify relevant HPSE concepts through triangulation of conceptual literature, existing tools and the tacit knowledge of school stakeholders. The HPSE measurement tool was administered to 18 elementary schools through a principal and teacher survey and an environmental assessment, followed by the development of HPSE scores for each school. Testing for internal consistency of items was used to examine theorized concepts, and scores for each school are summarised. HPSE included eight conceptual dimensions with internal consistency ranging from α = 0.60 to α = 0.87. Total HPSE scores across schools (N = 18) ranged from 1 to 8 (mean = 3.94, SD = 2.1), with 28-65% of schools reporting 'high' on respective HPSE dimensions. Schools included a heterogeneous mixture of HPSE scores, particularly across different dimensions. Our novel approach to tool development allowed us to conceptualize HPSE using a flexible process comprising different types and sources of evidence. The HPSE tool holds potential for identification and measurement of critical components of different school context as it relates to HPS.

Examining intervention mechanisms of action using mediation analysis within a randomised trial of a whole-school health intervention

BACKGROUND

Interventions to modify school environments are effective in promoting young people's health across outcomes, but mechanisms are poorly understood. We assessed mediation in a trial of the Learning Together intervention, building on the recent publication of results of effectiveness for reducing bullying and benefits across secondary outcomes and generally good implementation fidelity.

METHODS

Within a cluster-randomised trial involving 40 English schools, we examined student-reported and staff-reported school climate and student-reported involvement with delinquent peers at 24-month and 36-month follow-up, assessing the reliability of measures and whether these mediated health outcomes at a final follow-up.

RESULTS

Response rates and reliability were good for student-reported but not staff-reported measures. The intervention increased student-reported but not staff-reported-positive school climate but, like effects on student health outcomes, these manifested only at a final follow-up. The intervention reduced student-reported contact with delinquent peers at an interim follow-up. Student-reported potential mediators measured at the interim follow-up were associated with most health outcomes at the final follow-up. Adjustment for student-reported school climate and contact with delinquent peers at the interim follow-up did not reduce the associations between trial arm and our health outcomes.

CONCLUSION

Despite being constrained by imperfect measures and by the late manifestation of impacts on student-reported school climate undermining ability to assess mediation, our study for the first time provides tentative evidence that mediation of intervention effects via improved climate and disengagement from delinquent peers is plausible. Our study provides the first evidence from a trial that whole-school interventions may work by modifying school environments and student relationships.

TRIAL REGISTRATION NUMBER

ISRCTN10751359.

A systematic review and synthesis of theories of change of school-based interventions integrating health and academic education as a novel means of preventing violence and substance use among students

BACKGROUND

Schools can play an important role in promoting health. However, many education policies and institutions are increasingly emphasising academic attainment targets, which appear to be diminishing the time available for health education lessons. Interventions that integrate both health and academic learning may present an ideal solution, simultaneously addressing health education and academic development. The theories of change underlying these interventions are therefore of interest, but are poorly studied.

METHODS

A systematic review of evaluations of interventions that integrate academic and health education for reduced substance use and/or violence was carried out. As part of this, reports describing theory were assessed for quality and data extracted. Theoretical data were synthesised within and across individual interventions using reciprocal translation and meta-ethnographic line of argument synthesis to produce an overall theory of change for interventions that integrate health and academic education to prevent substance use and violence.

RESULTS

Forty-eight reports provided theoretical descriptions of 18 interventions. An overarching theory that emerged was that eroding 'boundaries' at multiple and mutually reinforcing levels-by integrating academic and health education, by transforming relationships between teachers and students, by generalising learning from classrooms to the wider school environment and by ensuring consistent messages from schools and families-is intended to lead to the development of a community of engaged students oriented towards pro-social behaviour and away from substance use, violence and other risk behaviours.

CONCLUSIONS

Eroding 'boundaries' between health and academic education, teachers and students, classrooms and the wider school and schools and families were seen to be the most critical to establishing new frameworks of family, classroom or school organisation that are conducive to promoting both academic and social-emotional outcomes. Whether such interventions are feasible to implement and effective in reducing risk behaviours will be examined in other reports arising from the review.

Elementary and lower secondary school students' perceptions of the Health at School Programme: a case study in Belo Horizonte, Brazil

The Health at School Programme is a Brazilian inter-sector policy resulting from a partnership between the Ministries of Health and Education to expand health actions to public school students, with a view to the comprehensive education of primary and lower middle school students. This qualitative study was carried out in 2016 to investigate Brazilian schoolchildren's perceptions of activities under the Health at School Programme. Data were collected from schoolchildren eleven to fourteen years of age using the written report (essay) as the instrument. Analysis of the reports highlighted two themes: 1. the Health at School Programme as care, and 2. the Health at School Programme as benevolence. For some, the activities meant the possibility of health care, of identifying problems and arranging solutions, and the opportunity for gaining information and learning that may be beneficial in maintaining health - the offer was received passively, however; for others, they were a blessing, a favour, for which they showed their gratitude. The schoolchildren were passive and receptive, without being proactive enough to produce their own health. Co-responsibility seems to be a seed that is still germinating.

School poverty and the risk of attempted suicide among adolescents

PURPOSE

Existing theory and empirical work suggest that impoverished school contexts may increase the risk of mental health problems such as suicide. This study tests this hypothesis by investigating the longitudinal association between school income and attempted suicide among American adolescents.

METHODS

Logistic regression models were used to estimate the association between school income and suicidal attempts among all adolescents and among those with suicidal thoughts, respectively. Data come from the National Longitudinal Survey of Adolescent Health, a nationally representative sample of American adolescents across 132 middle and high schools (N = 12,920).

RESULTS

Among all adolescents, the prevalence of attempted suicide was higher in low-income schools compared to middle-income schools for boys but not girls. Among those with suicidal thoughts, the prevalence of attempted suicide was also higher in low-income schools compared to middle- and high-income schools for boys only. Differences between middle- and high-income schools were not observed, suggesting that school income may only impact attempted suicide when high levels of deprivation are present. These significant associations persisted after adjusting for established risk factors such as prior suicidal attempts.

CONCLUSION

Highly impoverished school contexts may increase the risk of attempted suicide for boys. Future research exploring the mechanisms underlying this association may help inform the development of more effective suicide-prevention interventions.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

Mechanisms of implementing public health interventions: a pooled causal mediation analysis of randomised trials

BACKGROUND

The World Health Organization recommends that nations implement evidence-based nutritional guidelines and policies in settings such as schools and childcare services to improve public health nutrition. Understanding the causal mechanism by which implementation strategies exert their effects could enhance guideline implementation. The aim of this study was to assess the mechanisms by which implementation strategies improved schools and childcare services' adherence to nutrition guidelines.

METHODS

We conducted a mechanism evaluation of an aggregated dataset generated from three randomised controlled trials conducted in schools and childcare services in New South Wales, Australia. Each trial examined the impact of implementation strategies that targeted Theoretical Domains Framework constructs including knowledge, skills, professional role and identity, environmental context and resources. We pooled aggregated organisation level data from each trial, including quantitative assessments of the Theoretical Domains Framework constructs, as well as measures of school or childcare nutrition guideline compliance, the primary implementation outcome. We used causal mediation analysis to estimate the average indirect and direct effects of the implementation strategies and assessed the robustness of our findings to varying levels of unmeasured and unknown confounding.

RESULTS

We included 121 schools or childcare services in the pooled analysis: 79 allocated to receive guideline and policy implementation strategies and 42 to usual practice. Overall, the interventions improved compliance (odds ratio = 6.64; 95% CI [2.58 to 19.09]); however, the intervention effect was not mediated by any of the four targeted Theoretical Domains Framework constructs (average causal mediation effects through knowledge = - 0.00 [- 0.05 to 0.04], skills = 0.01 [- 0.02 to 0.07], professional role and identity = 0.00 [- 0.03 to 0.03] and environmental context and resources = 0.00 [- 0.02 to 0.06]). The intervention had no significant effect on the four targeted Theoretical Domains Framework constructs, and the constructs were not associated with school or childcare nutrition guideline compliance. Potentially, this lack of effect could be explained by imprecise measurement of the mediators. Alternatively, it is likely that that the interventions were operating via alternative mechanisms that were not captured by the four Theoretical Domains Framework constructs we explored.

CONCLUSIONS

Even though public health implementation strategies led to meaningful improvements in school or childcare nutrition guideline compliance, these effects were not mediated by key targeted constructs of the Theoretical Domains Framework. Future research should explore the mechanistic role of other Theoretical Domains Framework constructs and evaluate system-level mechanisms informed by an ecological framework.

TRIAL REGISTRATION

All trials were prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 . Registered 15/05/2013; ACTRN12614001148662 . Registered 30/10/2014; ACTRN12615001032549 . Registered 1/10/2015).

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

The picture of health: examining school-based health environments through photographs

Health-promoting schools (HPS) is an effective approach to enhance the health and well-being of children and youth, but its measurement remains a challenge considering contextual differences across school environments. The purpose of this study was to qualitatively explore the physical features of the school environment through photographs of schools that had implemented an HPS approach compared with schools that had not. This study used a descriptive approach, wherein physical features of the school environment were distilled through visual images and qualitatively analyzed. School environment data were collected from 18 elementary schools (10 HPS, 8 comparison schools) from a school board in rural Nova Scotia (Canada). Evaluation assistants captured photographs of the physical school environment as part of a broader environment audit. Overarching themes included the promotion, access and availability of opportunities for healthy eating and physical activity, healthy school climate and safety and accessibility of the school. The photographs characterized diverse aspects of the school environment and revealed differences between schools that had implemented an HPS approach compared with schools that had not. There were increased visual cues to support healthy eating, physical activity and mental well-being, and indications of a holistic approach to health among schools that implemented an HPS approach. This research adds to understanding the environmental elements of HPS. The use of photographic data to understand school environments provided an innovative method to explore the physical features of schools that had implemented an HPS approach.

Characteristics of health-promoting schools from Iranian adolescents' point of view

AIM

Although characteristics of health-promoting schools are mentioned in the World Health Organization guidelines, different countries need to design more details of indicators for assessing these schools according to their social and cultural context. The aim of this study was to investigate characteristics of health-promoting schools from Iranian adolescent girls' point of view.

MATERIALS AND METHODS

In this cross-sectional study, 2010 middle school and high school female adolescents were selected from randomly selected schools in Mazandaran province, Iran. They completed a self-completion questionnaire around their views about characteristics of health- promoting schools. Data were analyzed using descriptive statistics and an independent t-test.

RESULTS

It is revealed that from Iranian adolescents' point of view the most important feature of health-promoting schools was the schools with no stressful exams and where notices are kindly given to students for their mistakes.

CONCLUSION

The results suggest that there is a need for more measurable standards of health-promoting schools based on the socio-cultural context of both developing and developed countries.

Relationships Among Student, Staff, and Administrative Measures of School Climate and Student Health and Academic Outcomes

BACKGROUND

School climate is an integral part of a comprehensive approach to improving the well-being of students; however, little is known about the relationships between its different domains and measures. We examined the relationships between student, staff, and administrative measures of school climate to understand the extent to which they were related to each other and student outcomes.

METHODS

The sample included 33,572 secondary school students from 121 schools in Los Angeles County during the 2014-2015 academic year. A multilevel regression model was constructed to examine the association between the domains and measures of school climate and 5 outcomes of student well-being: depressive symptoms or suicidal ideation, tobacco use, alcohol use, marijuana use, and grades.

RESULTS

Student, staff, and administrative measures of school climate were weakly correlated. Strong associations were found between student outcomes and student reports of engagement and safety, while school staff reports and administrative measures of school climate showed limited associations with student outcomes.

CONCLUSIONS

As schools seek to measure and implement interventions aimed at improving school climate, consideration should be given to grounding these efforts in a multidimensional conceptualization of climate that values student perspectives and includes elements of both engagement and safety.

School composition, school culture and socioeconomic inequalities in young people's health: Multi-level analysis of the Health Behaviour in School-aged Children (HBSC) survey in Wales

Health inequalities emerge during childhood and youth, before widening in adulthood. Theorising, testing and interrupting the mechanisms through which inequalities are perpetuated and sustained is vital. Schools are viewed as settings through which inequality in young people's health may be addressed, but few studies examine the social processes via which institutional structures reproduce or mitigate health inequalities. Informed by Markham and Aveyard's theory of human functioning and school organisation, including their concept of institutional boundaries, critical theories of marketisation and the concept of micro-political practices within schools, this paper presents analysis of student survey data (N = 9055) from 82 secondary schools in Wales. It examines the role of socioeconomic composition, social relationships at school and institutional priorities in mitigating or perpetuating health inequality. It finds that affluent schools were most unequal in terms of student health behaviours and subjective wellbeing. In relation to health behaviours, students from affluent families accrue a disproportionate benefit. For wellbeing, students from poorer families reported lower subjective wellbeing where attending more affluent schools. Student-staff relationships appear to be a key mechanism underpinning these effects: poor relationships with staff were predicted by a pupil's position within schools' socioeconomic hierarchy and associated with worse health outcomes. That is, students from the poorest families reported better relationships with teachers where attending less affluent schools. Universal approaches engaging with these social processes are needed to reduce health inequalities.