Background
Adolescence offers a key opportunity for early intervention with preventive approaches to promote health and well-being across the life course [
1,
2]. There is a clear and well-evidenced link between young people’s physical health, emotional health and well-being, and their cognitive development and learning [
3‐
5]. Schools offer a pivotal setting for this with evidence suggesting that focusing on health within schools improves educational attainment [
4‐
7].
International guidance has focused on adopting a whole school approach to young people’s health and well-being for several years, namely the World Health Organization’s (WHO) Health Promoting Schools (HPS) Framework [
8] which has been re-advocated in recent years with WHO calling for making every school a health promoting setting [
9]. Whole school approaches involve all parts of the school working together and sharing a commitment, ethos and culture towards health and well-being. The HPS Framework comprises of health education being addressed in the school curriculum, health and well-being promotion through changes to the school environment and schools engaging with families and communities to help strengthen these health messages. Public Health England published guidance on the 8 principles to promoting a whole school approach to mental health and well-being more specifically, which include; enabling student voice to influence decisions, working with parents and carers and identifying need and monitoring impact of interventions [
3]. Literature on embedding whole-school approaches to health and well-being discusses developing supportive policy (e.g. anti-bullying), the potential for schools to re-shape their identity through prioritising values such as care, respect and empathy, as well as schools creating a culture that enables young people to feel confident talking about how they feel [
10,
11]. Review-level evidence suggests that a whole-school approach is effective in encouraging healthy behaviours in young people including physical activity, healthy eating, and in prevention of tobacco use and bullying [
12].
Despite growing recognition of school-based health improvement, there remain a number of barriers to improving health and well-being in this context, including financial constraints, schools focussing on educational outcomes and school performance and limited understanding about effective health interventions [
13]. One established method for overcoming these barriers has been the creation of School Health Research Networks (SHRNs). SHRNs use a whole system approach to facilitate health improvement in schools in that it brings together stakeholders and communities to develop a shared understanding of how best to improve school-aged children’s health and well-being [
14], a collaborative model that goes beyond typically commissioned school surveys. System-based approaches look at the interrelationships between components of a system (e.g. a school) and the broader system as a whole (e.g. wider educational and government systems) [
15]. Although established SHRNs exist with the UK (SHRN, Wales;
https://www.shrn.org.uk/ and SHINE Scotland;
https://shine.sphsu.gla.ac.uk/) as well as internationally (COMPASS, Canada;
https://uwaterloo.ca/compass-system/), a SHRN has yet to be implemented in England. These networks help schools work with researchers to generate and use good quality evidence regarding health improvement [
16].
Each country has their own unique context and while we can learn from experiences of SHRNs in other countries, we cannot simply replicate what these networks have done and expect it to work in the same way. We therefore require country-specific research to understand the unique barriers and facilitators to developing and sustaining SHRNs. In comparison to Wales and Scotland, England has a diverse school system with a variety of school types including Grammar schools that select students based on academic achievement, Academy schools that are state-funded but independent from local authorities and therefore decide on their own curriculums, and Free schools which are similar to academies but run by charities. Only a very small proportion of schools in England are still maintained by local government (11%).
Academy schools, have autonomy over their national curriculum as well as how they support and teach about mental health and well-being [
17].A recent qualitative study revealed a wide amount of variability amongst academy trust leaders in how they perceive the role of academies in promoting health and well-being amongst students [
13]. This study also revealed differences in whether multi-academy trusts (those responsible for more than one school) adopt a centralised strategy to health promotion, or allow individual schools autonomy. Existing structures in England means that there are different decision making approaches for health and well-being in different schools and therefore a SHRN needs to be sufficiently flexible to fit in with these varying structures, and this research will help us understand how best to do this.
One existing study in England testing a similar model to a SHRN is the BeeWell study (
https://gmbeewell.org/), an annual well-being survey of secondary school pupils across Greater Manchester. Although BeeWell have adopted a regional approach in England, Greater Manchester is a city-region with a combined authority (a group of two or more local government councils that collaborate/take collective action). SW-SHRN is more ambitious in that it is seeking to create a network across a larger geographic area, made up of 15 separate local government administrative areas. Therefore, we want to understand the barriers and enablers to doing this at scale.
Our pilot study created a network of 18 schools from 6 local authorities in the South West of England. This paper reports on a qualitative process evaluation of implementing this pilot network to determine the barriers and facilitators to inform the expansion and continuation of the existing pilot network. A working logic model of SW-SHRN can be found within the study protocol paper [
18].
We aimed to answer the following four research questions:
i.
What are the key issues that impact the successful delivery and running of the SW-SHRN?
ii.
What key information is required by schools to maximise the impact of the SW-SHRN?
iii.
What data does the SW-SHRN need to provide to be successful and informative?
iv.
What is required for the SW-SHRN to be sustainable long term? (sustaining school recruitment, retention and sustaining partnerships to best support schools to improve student health and well-being)
Discussion
The aim of this study was to identify the key barriers and facilitators involved in setting up a regional SHRN in the South West of England and to identify opportunities for refinement of the network to enhance its sustainability. We identified four key themes (1) Key barriers to SW-SHRN; (2) Key facilitators to SW-SHRN: providing evidence-based support to schools; (3) Effective dissemination of findings; and (4) Longer-term facilitators: ensuring sustainability.
Barriers incorporated pressures on school time, different levels of prioritisation on student health and well-being in comparison to academic attainment, and competing with existing commissioned health and well-being surveys. These barriers are consistent with a recent systematic review of sustaining school-based mental health and well-being interventions [
21]. The review found that competing priorities and responsibilities often led to intervention delivery challenges and also highlighted the need for school interventions to be easy to use or implement and well-organised. These two findings are in line with our study results relating to competing school priorities and discussion of time pressures and reducing burden on schools.
Although the links between health improvement and educational attainment are well-evidenced within the academic literature, it seems particularly important to clearly communicate this link to school staff, local authorities and academy trusts, particularly with reference to our findings regarding competing priorities between health and well-being and academic achievement and reassuring schools that focussing on health and well-being is not diverting resource away from the core curriculum and attainment. Previous research from the Welsh SHRN demonstrates emerging evidence of better educational outcomes in schools with more extensive health improvement policies and practices [
22] which is another important factor when communicating the benefits to schools of participating in a SHRN.
To address these barriers, SW-SHRN aims to provide collaborative opportunities for schools to share best practice between one another and across different local authorities in an effort to create an active learning network. By building an active learning network that multiple partners benefit from (similar to the Welsh and Scottish model) we hope to make the research/survey burden worthwhile for schools and go above and beyond existing survey provider offerings. As SW-SHRN grows and more schools participate, we hope the network can offer a more standardised approach to health and well-being surveys across the region and in turn reduce the number of survey requests that secondary schools receive. There are also unknowns on how commercial survey companies deal with ethical requirements, data security and ownership of data, therefore a university-led SHRN hopes to provide schools a robust and secure method of collecting student data.
It will be important to take an inclusive approach in terms of promoting the network and recruiting to the network to ensure all the relevant education infrastructures are incorporated to maximise the growth of the network given the diverse school system in England. Previous literature has evidenced that collaboration with the education sector is critical when developing health-promoting schools programmes [
23].
A key facilitator to SW-SHRN is the ability to provide schools with evidence-based information to enhance their understanding of mental health and well-being in school populations as well as identifying health needs and challenges, for example subgroups of students requiring more support or intervention. What seemed to set SW-SHRN apart from existing school surveys was the individualised feedback reports. Within these reports, schools valued the use of benchmarking data to allow them to see where they sit in the context of all participating schools in the region as well as the break down of data by gender, year group and socio-economic status. In turn, these detailed reports aim to allow schools to more effectively target health areas both within the curriculum as well as through targeted resources and interventions.
There was also a need to make network outcomes and impacts clear to schools, local authorities, and wider stakeholders, which echoes findings from intervention developer perspectives of evidence-based interventions in schools [
24]. A common suggestion to make outcomes and impacts visible was to provide an online platform containing network data which incorporates evidence summaries and policy impacts which would be available to schools and all key stakeholders. A key finding was the need to embed SW-SHRN findings in the wider evidence base and put the findings in context of existing knowledge of young people’s health and well-being, as well as linking findings to existing policies and practice [
24]. This also aligned with supporting schools to interpret their data and implement meaningful change, schools felt they required support from the research team to translate survey data into action.
Schools and stakeholders reflected on how to ensure sustainability of SW-SHRN. Sustainability within the context of the network refers to how to sustain the growth of the network (number of schools, academy trusts and local authorities involved), sustaining active involvement from participating schools (e.g. engaging in repeat surveys and acting on findings) and sustaining meaningful collaborations between stakeholders. Stakeholders discussed the importance of the network maintaining a wider systems perspective, continued conversations with key stakeholders and embedding network findings within wider national policy.
One important aspect relating to sustainability is the role future Ofsted frameworks could play in sustaining SW-SHRN if health and well-being were to form a larger part of future frameworks. Stakeholders saw value in making use of SW-SHRN data to inform student need and modifying provision accordingly (e.g. PSHE curriculum), which could then be presented to Ofsted to showcase meaningful health and well-being activity. An important area of future research could focus on how best to mandate routine monitoring of health and well-being provision in schools.
Findings revealed the potential SW-SHRN data holds to support and inform both regional and national policy and planning, and the implications this may have on who may support funding the network in the future. Working at a systems level has been effective for the Welsh School Health Research Network, their network has been effectively embedded into the system and plays a key role in national and regional planning [
14].
The suggestions from participants regarding joined up working, influencing questions to drive policy, and understanding challenging areas through comparison with other schools demonstrate the need for connecting multiple systems and structures and a requirement for the network to monitor and intervene at multiple levels (e.g. school level, local authority level, government level). Together, these suggestions reflect the need for the network to take a systems-based approach.
A possible area of future expansion for the network noted by several stakeholders could be the inclusion of primary schools, as well as 16+, and alternative provision settings, to allow SW-SHRN to provide a more complete picture of health and well-being across all school settings and in all age groups. Primary schools were of particular interest as an area for expansion, both to allow for earlier intervention, to allow for longitudinal tracking of health and attainment outcomes and also due to many multi-academy trusts comprising of both primary and secondary schools and therefore wanting a network that was accessible for all of their schools. However, expanding to primary schools would need careful consideration, particularly in terms of how to sustain such a large network if expanded given the barriers identified so far.
Sustainability of public health interventions in schools remains relatively underexplored in comparison to health care and a recent review highlights particular difficulties with retaining senior leadership contacts given frequent staff turnover in schools [
25]. Additionally, it will be important to refine definitions of sustainability relating to SW-SHRN as the network continues to develop [
26].
One incentive to join the network could lie in its multiple forms of research participation, particularly for those schools who are less active in research. SW-SHRN offers involvement in a population health survey, 1:1 feedback on a tailored school report, qualitative interviews and focus groups with young people, as well as the school environment survey that may help schools reflect on their current health and well-being policies. A possibility for the network as it develops could be offering schools flexibility on which aspects of research they participate in.
An important overall finding from this study was the general unified opinions or advice given from key stakeholders, suggesting agreement and consensus around the importance of routine collection of health and well-being outcomes in young people. However, there were varied opinions and priorities across individual schools, particularly how schools would make use of SW-SHRN data and how much support schools felt they needed from the University in making meaningful changes as a result of the data they received from the network. This reinforces the individual nature and unique set-up of each school or academy and the need to offer a flexible and tailored research agenda to meet individual school needs. SW-SHRN in the future, for example, could offer different levels of school involvement depending on individual school preferences.
Findings from this evaluation will be used to develop, adapt and enhance the expansion of School Health Research Networks in England, with particular focus towards creating meaningful change in schools and supporting schools to effectively make use of the data generated from these networks. SW-SHRN will continue to routinely seek feedback from participating schools, local authorities and academy trusts to continue refining the model and prioritise areas of future expansion.
Strengths and limitations
This is the first regional School Health Research Network to be set-up in England. This study benefits from seeking perspectives from a wide variety of school staff, six different local authorities across the South West, as well as advice from a wide range of relevant stakeholders including government departments, charities, researchers, and existing providers of health and well-being initiatives for young people. However, some limitations must also be acknowledged. Although this pilot study tests a regional School Health Research Network in the South West of England, school staff and local authority interviews only covered seven of the 15 local authorities in the region, therefore the findings may not translate to the whole region and it will be important for future SW-SHRN recruitment to target these remaining eight local authorities to gain their perspectives. Another limitation is that only one individual per school and local authority were interviewed which means we were not able to explore how far there were diverse opinions within schools or local authorities. Future work could benefit from the use of focus groups to allow discussion between members of staff and perhaps include combinations of school staff, local authority staff, and wider key stakeholders to encourage conversation around differing viewpoints.
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