Background
Schools continue to be key settings for public health strategies aiming to improve health and reduce health inequalities for several reasons. First, the years young people spend at school are a formative period in their ‘health career’ [
1], with socioeconomic inequalities in many health-risk behaviours, such as smoking, alcohol misuse and sedentary behaviour, emerging and becoming entrenched during this period [
2‐
4]. Second, where education is provided universally, schools provide access to the vast majority of young people and thus have potential to improve health at a population level [
5]. Third, the largest amount of public spending focussed on young people is typically made via national education systems, with staff professionally trained to support young people’s development. Fourth, there is now clear evidence that the school environment itself can influence young people’s health in various positive and negative ways [
6]. Finally, there is growing evidence that promoting students’ health and wellbeing is synergistic with improving educational attainment [
7].
For these reasons the World Health Organisation (WHO) developed the tripartite Health Promoting Schools (HPS) framework, focused not only on health education but also on promoting students’ health through the physical and social environment of school and involving families and wider communities in school-life [
8,
9]. The HPS framework advocates the re-orientation of the whole school system towards health, with health improvement becoming a normalised part of what schools do, rather than a set of bolt-on activities. A systematic review of the effects of interventions adopting this HPS framework found that they produce small but significant public health benefits [
8]. Another systematic review of the effects of modifying the school environment to improve students’ health also supported the use of the HPS framework [
6]. Interventions which include such ‘higher-level’ environmental components also tend to be more cost-effective [
10], and may be less likely to generate socioeconomic inequalities than individually focused, educational approaches [
11].
However, to deliver significant public health gains requires HPS interventions to be adopted, implemented and maintained universally throughout national school systems [
6]. This is far from straightforward. MRC guidance for evaluating complex interventions emphasises the need to consider whether complex interventions will be implementable on a wider scale throughout their development and evaluation [
12]. However, evaluation practice has continued to be dominated by models in which complexity is conceived purely as a characteristic of the intervention, rather than of the systems into which interventions are to be delivered [
13]. Interventions can perhaps best be understood as events within systems [
14], or attempts to harness and re-orient existing system dynamics towards promoting health. Schools can be conceptualised as complex adaptive systems; their functioning is shaped by interactions among diverse and ever changing agents, while their ethos and network structures may support or impede the integration of new health improvement actions [
15]. Hence, beginning to understand the complexities of delivering universal intervention approaches within school systems requires an understanding of what schools already do, and why.
To date, integration of HPS activities has been challenging in many contexts, possibly due to issues such as inadequate provision of supporting structures, resources and appropriate skills within the school setting [
15,
16]. Qualitative studies exploring the implementation of interventions using the HPS framework have found that while incremental changes to a school’s practices, such as delivery of health education within the curriculum, can be enacted relatively quickly, more fundamental changes to the functioning of school systems, such as modifying a school’s environment or engaging parents and communities in health improvement activity, often prove more challenging [
17‐
19]. However, variations in schools’ commitment to student health and their delivery of activities at a
population level remain under-researched and under-theorised – for example, whether levels of commitment and delivery vary systematically according to schools’ socio-economic profiles or size, and what factors are associated with any variations in commitment to health and implementation across schools. Understanding population-level variations in schools’ commitment to student health and implementation of health improvement activities is vital to ensure that health inequalities are not exacerbated – rather than reduced – via investment in school health.
There is some evidence from Wales that pupils attending more affluent schools tend to report healthier behaviours than those attending poorer schools after adjustment for family-level socio-economic status (SES), while gradients by family-level SES are greatest in affluent schools [
20]. Neo-materialist theories of health inequalities argue that the provision of public and social services, such as education, and their capacity to improve health, varies systematically according to differences in communities’ socio-economic characteristics and this, in turn, partly explains the extent of the social inequalities observed in health outcomes in countries such as the UK [
21]. These theories address some of the limitations of traditional, cruder material explanations, situating health inequalities in the context of public policies and recognising the social importance of place for shaping institutions, local cultures and individuals’ behaviours [
22].
Neo-materialist theories also draw attention to the ‘inverse care law’, whereby the availability of good medical or social care has been found to vary inversely with the need of the population served [
23]. An inverse care law in relation to provision of school health improvement activity could potentially offer one explanation for the aforementioned socioeconomic inequalities in health behaviours previously observed between schools in Wales [
20]. However, whether commitment to health or delivery of school health improvement activity are patterned by school-level socioeconomic compositions has yet to be tested. Empirical evidence on the role of school size on education and health outcome is also a major blindspot at present; what little evidence there is of effects on educational outcomes remains equivocal [
24]. Larger schools are perhaps likely to possess more complex system-level structures, including larger numbers of sub- and supra- systems [
15], and as such achieving change may be more difficult. Conversely, the greater diversity in agents within larger systems may mean that there is a broader skills mix to draw upon in implementing new actions, or a greater number of staff committed to student health.
Previous empirical studies have identified some factors that may explain why adoption and implementation of health improvement activities varies across schools. A review of the implementation literature suggested the following eight factors facilitated the implementation of health improvement activities in schools: preparation and planning; policy support; opportunities for professional development; support and buy-in from leadership; supportive relational and organisational context; student participation; partnership working; and the potential for sustainability [
25,
26]. Relating to Rowling and Samdal’s theme of ‘support and buy in from leadership’, the role of ‘champions’ in engaging and motivating other staff, parents and students, and involving the whole school community in health improvement, has been emphasised by advocates of the HPS approach [
27,
28]. Drawing on qualitative data collected in Scottish schools, Inchley et al. [
17] argue that where this role is assigned to a senior figure, a school is more likely to achieve health promoting school status, due to the greater degree of leverage and influence such individuals hold over the system as a whole. Other studies have also identified the importance of senior management commitment to student health through the development of action plans, and regularly reviewing schools’ progress against them via local data [
29,
30]. However, no studies have empirically tested the importance of these factors across a large number of schools.
To address these empirical gaps, this paper draws on school-level data from a large, representative sample of secondary schools in Wales. It begins by mapping variability in the priority given to student health and their management systems and structures for health improvement, examining whether student health is identified as a priority area, the presence of regularly reviewed written action plans for health, the seniority of individuals tasked with leading health improvement activity and the use of data to inform health improvement. Our analyses test the ‘inverse care law’ through use of school-level data on social deprivation, and also whether organisational commitment and management vary systematically according to school size. Subsequently, the paper focuses on the extent and nature of variability in the delivery of activities according to specific domains of health improvement activity, including food and fitness, substance use, and mental and emotional health. Variations by organisational commitment to health, school-level deprivation and school size are examined for each of these areas of activity.
Discussion
This study demonstrates a marked diversity in organisational commitment to pupil health improvement among secondary schools in Wales; about half identify student health as a priority area, with more prioritising student mental and emotional health (52.2 %) than physical health (43.3 %). About half report that they have written action plans in place for student health. Consistent with earlier studies of the HPS model which cite leadership, school structures and policies, information, collaboration, resources and political support as factors that aid implementation [
33], organisational commitment to student health was consistently correlated with a wide range of health improvement activity. Contrasting with earlier literature [
17], whether leadership responsibility was assigned to a more senior or junior figure was not correlated with school health improvement actions. Hence, it may be that whether staff assigned responsibility for school health are fully backed by senior management is more critical than whether they are themselves senior figures within the school.
While it is perhaps encouraging that half of schools view pupil health as a priority, it remains concerning both that student health appears to be given limited priority by senior management within a large proportion of schools, and that this appears to translate into more limited delivery of health improvement activity. Viewing school-based interventions as events within complex systems [
13,
14], it is perhaps likely that in schools which see health improvement either as a low priority activity or as something which conflicts with educational goals, existing system structures will block the flow of new information and activities throughout the system [
15]. Hence, the universal delivery of such approaches needed to realise their potential public health impact may prove difficult to achieve, unless concerted efforts are made to persuade many schools of the value of promoting pupil health. A tendency for health and education to be viewed as conflicting priorities is perhaps evidenced by findings such as the marked drop off in weekly time devoted to physical education once pupils entered the final 2 years of compulsory education (the time period during which school-leaving qualifications are pursued in UK schools). However, this approach to school management and leadership is paradoxical in light of the educational benefits of promoting student health [
7].
Notably however, while practices varied substantially between schools, in contrast to neo-materialist explanations of health inequality – which emphasise the role of the unequal distribution of services and resources in perpetuating inequality there was no evidence of an ‘inverse care law’ [
23] – health improvement activity was neither prioritised nor delivered to a lesser extent in poorer schools. Indeed, there was a tendency for a greater volume of health improvement activity in schools with more deprived intakes. Hence, there is some suggestion that schools in poorer areas may have more comprehensive health improvement actions in place, perhaps as a means of countering the effects of socioeconomic deprivation on pupil health. Hence, while between school SES inequalities in health-related behaviours have been reported in Welsh schools [
20], these are unlikely to be explained by systematic variability in school commitment to pupil health or in the quantity of health improvement activity.
It is perhaps plausible that other features of more deprived school contexts impede the ability of health improvement activity to work as effectively, or that a higher volume of activity is delivered, though not with greater quality. Our recent systematic review suggests that universal interventions delivered via schools are equally likely to narrow or widen inequality [
34]. An established body of educational literature shows that schools in poorer areas face greater challenges in recruiting and retaining high quality teaching staff, with implications for teaching quality [
35]; implications of issues such as these for the delivery of health improvement have not been explored. Notably, though there is some evidence that more structural interventions may be necessary to reduce inequality [
34], deprivation was more strongly associated with increased health education than with environmental intervention or family involvement. There was also no evidence of an association between school size and the volume of health improvement actions, although a consistent trend in the direction of more activity in larger schools.
The study benefits from sampling of a large and nationally representative range of schools throughout Wales. However, limitations include the reliance on self-report measures of school health improvement actions, as well as a focus on the quantity of health improvement activity rather than its quality or the extent to which the manner in which it was delivered is grounded in evidence. It may be for example that having a small number of well implemented evidence-informed programmes to improve pupils’ health is more beneficial than having a large number of different activities. The questionnaire was also not designed explicitly to capture consistency with an HPS framework, and hence measures such as parental and community involvement are limited and may have overlooked a wide range of additional activities delivered within Welsh Schools. Though widely used [
34], there has been some criticism of the use of free school meal entitlement as a marker of SES.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
GM conducted the analysis, wrote the first draft of the manuscript and integrated author comments and revisions into the final draft. HL assisted in developing the paper plan and drafting sections of the manuscript. AF contributed to survey design and redrafted sections of the manuscript. GH contributed to survey design and redrafted sections of the manuscript. SM contributed to survey design and redrafted sections of the manuscript. All authors read and approved the final manuscript.