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Title: Title slide


1
The Evidence Base for Health Promotion in
Schools What does it tell us and what does it
not?
Sarah Stewart-Brown Professor of Public
Health Director Health Sciences Research
Institute Warwick Medical School
2
Plan
3
Plan 1
  • Findings from Reviews of Reviews of Health
    Promotion in Schools
  • Health promoting schools and health promotion in
    schools two systematic reviews. Lister Sharpe
    et. al. Health Technology Assessment 1999(3) 22
  • What is the evidence on school health promotion
    in improving health or preventing disease, and
    specifically, what is the effectiveness of the
    health promoting school approach. Stewart-Brown
    2006
  • Health Evidence Network WHO Europe
    http//www.euro.who.int/document/e88185.pdf

4
Plan 2
  • Recent reviews of mental health promotion in
    schools
  • Systematic Review of the effectiveness of
    interventions to promote mental wellbeing in
    children in primary education.
  • Report 1 universal approaches non violence
    related outcomes National Institute for Health
    and Clinical Excellence June 2007
  • http//www.nice.org.uk/guidance/index.jsp?action
    downloado43911
  • Systematic Review of the effectiveness of
    interventions to promote mental wellbeing in
    primary schools. Report 3 universal approaches
    which focus on prevention of violence and
    bullying NICE Sept 2007
  • http//www.nice.org.uk/guidance/index.jsp?action
    downloado43912
  • Mental wellbeing of children in primary
    education targeted /indicated activities NICE
    July 2007
  • http//guidance.nice.org.uk/download.aspx?o441004

5
Plan 3
  • Reflect on lessons from these reviews
  • Reflect on future directions for school health
    promotion in Europe

6
Some Caveats
  • My background
  • Limitations of review level evidence

7
Review level evidence
  • Places more emphasis on the quality of the study
    than on the quality of the programme or
    intervention
  • It is often difficult to discover from reviews
    exactly what was involved in successful
    programmes or intervention

8
  • In the field of health promotion
  • Randomised controlled trials are inappropriate
    misleading and unnecessarily expensive
  • WHO European Working Group on Health Promotion
    Evaluation 1998 EUR/ICP/IVST 05 0103
    CopenhagenWHO Regional policy for Europe

9
  • In the field of health promotion
  • Randomised controlled trials are inappropriate
    misleading and unnecessarily expensive
  • WHO European Working Group on Health Promotion
    Evaluation 1998 EUR/ICP/IVST 05 0103
    CopenhagenWHO Regional policy for Europe
  • In the field of policy making
  • Interventions which have not been subject to
    randomised controlled trials are regarded as
    unproven

10
New UK Medical Research Council Guidance on
developing and evaluation complex interventions
Feasibility and piloting
Evaluation
Development
Implementation
11
New UK MRC Guidance on developing and evaluation
complex interventions
  • Evaluation phases do not have to follow a linear
    sequence
  • Experimental designs, though preferred are
  • recognised as sometimes impractical
  • Complex interventions may work better if tailored
    to local circumstances ie not standardised
  • Process evaluation important alongside outcome

12
Systematic Reviews
  • Strengths
  • Comprehensive
  • Controlled studies
  • Clear inclusion criteria
  • Critical appraisal
  • Weaknesses
  • Only include experimental studies
  • Limited to quantitative outcomes
  • Information about programme implementation and
    content often scant
  • Limited by inclusion / exclusion criteria

13
Health promoting schools and health promotion in
schools two systematic reviews. HTA 1999(3) 22
  • Two Reviews
  • Review of Primary Studies of Health Promoting
    Schools
  • Review of Reviews of Health Promotion in Schools
  • All experimental studies before and after and
    controlled
  • All good quality systematic reviews

14
Systematic Reviews of Health Promotion in Schools
Substance use
Mental health
Sexual health
Nutrition exercise
Accident prevention
Other
15
Systematic Reviews of Health Promotion in
Schools 1999
  • HP in schools not reliably effective
  • Most interventions classroom based, but
    successful interventions more likely to include
  • an environmental component
  • and/or family or community component

16
Systematic Reviews of Health Promotion in Schools
1999
  • Among classroom based interventions
  • Knowledge easy to change
  • Behaviour and attitudes much harder to influence
  • Healthy eating and physical activity programmes
    more successful that drug or alcohol misuse
    programmes
  • Programmes incorporating life skills education
    and involving peers more promising than those
    that didnt

17
What is the evidence on school health promotion
in improving health or preventing disease, and
specifically, what is the effectiveness of the
health promoting school approach. Sarah
Stewart-Brown Health Evidence Network WHO 2006

18
What is the evidence on school health promotion
in improving health or preventing disease, and
specifically, what is the effectiveness of the
health promoting school approach. HEN WHO 2006

2
4
N. of Reviews
19

Aspects of Mental Health HEN Report WHO 2006
  • Prevention
  • Antisocial behaviour
  • Criminality/ violence
  • Bullying
  • Depression
  • Suicide
  • Anxiety
  • Promotion
  • Self esteem
  • Social skills
  • Problem solving
  • Conflict resolution
  • Emotional literacy
  • Peer relationships

20
HEN Review Results
  • Mental health promotion programmes are effective,
    particularly if they
  • Involve the whole school
  • Make changes to psychosocial environment
  • Personal skill development
  • Involvement of parents and wider community
  • Implement over long period of time
  • Moderate to large effect sizes reported

21
HEN Review Results
  • Healthy Eating and Physical Activity Programmes
  • Amongst the most sophisticated
  • Effective if involved changes to school
    environment
  • Involved parents and wider community
  • A range of different type of programme proved
    effective

22
HEN Review Results
  • Substance use programmes were the least
    effective. At best they
  • delay onset
  • reduce quantity of drugs consumed
  • No new reviews of safe sex programmes
  • Driver education ineffective

23
  • Systematic Reviews of the effectiveness of
    interventions to promote mental wellbeing in
    children in primary education. NICE 2007
  • Universal approaches
  • Report 1- focus on non- violence related
    outcomes and
  • Report 3- focus on prevention of violence and
    bullying
  • Targeted approaches
  • Report 2- Mental Wellbeing in primary education
    targeted indicated activities

24
Population Approaches
Number of Individuals
Decreasing level of health problem
25
Targeted/indicated approaches
26
Targeted/indicated approaches
27
Universal approaches
Population mean
28
Universal approaches
29
NIHCE Reviews of approaches to mental health
promotion in primary schools
  • A significant evidence base exists
  • Universal
  • 23 Randomised Controlled Trials
  • 21 Controlled Trials
  • Targeted
  • 27 Randomsed Controlled Trials
  • 1 Controlled Trial
  • Health Economic
  • 0

30
NIHCE Reviews of approaches to mental health
promotion in primary schools
  • Great majority of studies carried out in US
  • Germany (3)
  • Stress management x 2 (Lohaus 1997, 2000)
  • Qi Gong (Witt 2005)
  • Netherlands (2)
  • Good Behaviour Game (Van Lier 2005)
  • UK (1)
  • Emotional disclosure (Reynolds 2000)
  • Spain (1)
  • Targeted ADHD prog (Miranda 2002)
  • Canada (7)
  • Australia (5)

31
NIHCE Reviews of approaches to mental health
promotion in primary schools
  • Findings Universal-
  • Wide range of interventions
  • classified by component parts
  • Only three interventions evaluated in more than
    one study.
  • Some interventions trialled with and without
    additional components, but not in the same study.
  • Study quality variable

32
NIHCE Reviews of approaches to mental health
promotion in primary schools
  • Findings Universal
  • Most universal interventions delivered by
    teachers
  • Some peer mentoring
  • Some psychologist delivery
  • Some combined with targeted approaches
  • High proportion of targeted interventions
    delivered by psychologists
  • Predominant focus antisocial behaviour and social
    skills
  • Some studies investigated- anxiety, depression,
    self concept, self esteem, peer relationships

33
Findings Universal-
  • Description of Programmes
  • Primarily curriculum (14)
  • Social skills, conflict management, problem
    solving, emotional literacy, coping
  • CB skills, Relaxation
  • eg PATHS, Second Step
  • Primarily behaviour management (6)
  • Teachers trained to manage behaviour in and
    outside classroom
  • Resources and games
  • eg Good Behaviour Game Peace Builders

34
Findings Universal-
  • Description of Programmes
  • Primarily anti- bullying (3)
  • Increased awareness
  • Reporting
  • Confronting
  • Olweus (Bullyproof your school)
  • Multi-component (16)
  • Curriculum, behaviour management, parenting
    support
  • eg LIFT, Resolving Conflict Creatively
  • As above plus changes to the school ethos and
    environment
  • Eg Seattle Social Development,

35
Outcome by type of Universal Intervention
Curriculum
Parenting plus
Whole school
Other
36
Good Quality Studies of Effective Universal
Interventions
  • Tri Ministry Study Canada Boyle 1999
  • Social skills training, teacher training, support
    for parenting (2 years)
  • PATHS plus parenting (CPPRG 1999)
  • Emotional literacy curriculum (57 lessons),
    teacher training on programme and behaviour
    support for parenting
  • Seattle Social Development Project (Hawkins
    1991,1999 2005)
  • Teacher training in behaviour management and
    modelling, social skills, parenting support
    (Permanent change)
  • LIFT programme (Reid Eddy Stoolmiller 1999-)
  • Parenting programme, social skills curriculum,
    Good Behaviour Game (3 months)
  • Peace Builders (Vazsonyi 2004, Krug 1997)
  • Cultural change to school five principles, peer
    mentoring, parenting support, peer mentoring
    (Permanent change)

37
Findings Targeted
  • Mostly delivered by psychologists
  • Short CBT based programmes for anxiety
  • better with parenting education
  • Multi-component approaches including parenting
    component for externalising behaviours
  • May be recruitment problems with parenting
    education

38
Messages
  • Evidence of effect
  • Need for multiple components
  • Teacher development
  • Parenting support
  • School ethos
  • Balance of universal and targeted
  • Balance of teacher delivered and specialist
    delivered

39
Mental Health in Schools

Pupil aggressive behaviour
Teacher aggressive behaviour
School Ethos
Teacher depression and anxiety
Pupil depression and anxiety
40
hippocampus
orbitofrontal cortex
amygdala
hypothalamus
41
Brain Development
  • The emotional and social brain is developed and
    sustained in the context of interpersonal
    relationships
  • The parent-child relationship is critical because
    children spend most time with their parents good
    quality relationships enable the child to develop
    self soothing
  • Early relationships set the thermostat on the
    stress response influencing a range of
    physiological processes and increasing the risk
    of disease
  • Early relationships set the scene for future
    relationships including parents relationships
    with their own children

42
Brain Development
  • By school age emotional and social responses to
    threat are ingrained in the brain
  • Relationships with teachers can enable these
    pathways to change and help vulnerable children
    develop the capacity to self sooth
  • The older the child the greater the skill of the
    teacher
  • The skills teachers need to form therapeutic
    relationships require robust mental health
  • The proportion of the adult population with
    really robust mental health is small

43
What promotes mental wellbeing in adulthood ?
  • Good social support
  • Respectful, empathetic relationships
  • Physical activity
  • Creative activity
  • Meditation mindfulness practices

44
A view on the way forward for Health Promoting
Schools
  • Put mental health promotion centre stage
  • Work on emotional and social aspects of school
    ethos and environment
  • Support teachers mental health and emotional and
    social development

45
A view on the way forward for Health Promoting
Schools
  • Introduce mindfulness practices
  • Meditation, Yoga, Qi Gong
  • Increase physical activity
  • Improve diet
  • Increase creative activity

46
Thank you for listening
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