NIHR Signal How to successfully implement a school-based health promotion programme

Published on 1 March 2016

There are four broad areas to consider when implementing a school-based health promotion programmes: preparing for implementation, introducing a programme within a school, embedding a programme into routine practice, and fidelity of implementation and programme adaptation. This review identified specific factors for success for each. This was based on 22 studies (some of them NIHR-funded) around health promotion interventions in UK schools. Common factors that improved the chances of successful implementation included engaging pupils, teachers and senior staff, explaining the value of the intervention in relevant terms, having a specific co-ordinator to support staff and enabling staff to discuss and resolve implementation issues. A wide range of health promotion programmes were considered, including healthy eating, smoking, alcohol consumption and accidental injuries.

The findings give pragmatic evidence-based advice on how best to implement school-based programmes. This has potential to minimise money being wasted because of the poor implementation of programmes known to work. It will be particularly helpful for school nurses and others.

How to successfully implement a school-based health promotion programme

Share your views on the research.

Why was this study needed?

The risk of developing many common diseases in the UK can be lowered by making lifestyle changes. For example, reducing salt intake to reduce the risk of heart disease or maintaining a healthy weight to reduce the risk of diabetes.

Many suggest that promoting healthy lifestyle choices – health promotion – should start early in life to help establish healthy habits early and prevent disease, rather than trying to reverse unhealthy habits later in life, or once illness had occurred. As such, school is recognised by NICE as an important setting for improving various aspects of health promotion, such as preventing excess weight gain, improving oral health and reducing smoking and alcohol use.

This review investigated the factors that contributed to successful or unsuccessful implementation of UK school-based health promotion programmes.

What did this study do?

This was a “realist” review – meaning it focused on the implementation of interventions, rather than their effectiveness. The first part of the review used 22 UK-based studies (some funded by NIHR) to produce a framework of the different aspects of implementation, known as “programme theories”. These programme theories were then tested and refined using a further 41 studies. Data were extracted until “theoretical saturation”, the point at which adding new studies is considered unlikely to yield further insight. Studies were also critically appraised so that the authors could indicate the quality of the evidence underlying their findings.

What did it find?

  • The review identified four “programme theories” affecting implementation success: preparing for implementation, introducing a programme within a school, embedding a programme into routine practice, and fidelity of implementation (how closely the reality matched the intention) and programme adaptation.
  • Preparing. Integration was more likely to be successful when systematically planned in line with the school’s existing responsibilities. This involved pre-delivery consultation. New or contentious programmes may need more consultation than well-established or uncontentious programmes. Pupils need to understand the relevance and benefits, and teachers and pupils need to feel supported. The authors identified the notion of reciprocity, with both teachers and pupils needing clear benefits (including non-health advantages, such as developing transferable skills) to participate. The new programme should be fitted in with current school activities.
  • Introducing. Successful implementation was more likely if health promotion programmes are integrated into the life of the school. This can be achieved through appropriate senior level support, a named co-ordinator showing leadership, and positive engagement with teachers, public and others involved in the programme delivery or participation.
  • Embedding. There was limited evidence informing how to best embed a programme into routine practice.
  • Implementing. Limited evidence also informed best approaches to ensure fidelity – i.e. how closely the programme stuck to the original aims. But elements to consider were around programme adaptation, and the elements of the programme that are essential, optional and adaptable by those delivering it.

What does current guidance say on this issue?

NICE guidelines relating to health promotion programmes in schools cover: alcohol interventions (PH7), physical activity for children and young people (PH17), smoking prevention in schools (PH23) and social and emotional wellbeing in primary education (PH12) and secondary education (PH20). Where implementation advice is provided, it reflects the findings of this review. For example, using a “whole school” approach to embed programmes into the school, family and wider community – such as in the case of oral health programmes (2014), smoking prevention (2010) and alcohol consumption (2007).

What are the implications?

The focus in research can often – and understandably – be on the effectiveness of an intervention, rather than how it can be best implemented in different contexts. Both are important for success. This review suggests implementation issues to consider when selecting and planning the implementation of health promotion programmes in schools. For instance, it may be helpful to identify which parts of a programme are standard and which could be adapted to fit the needs of local schools. The “programme theories” developed in this review should be considered by those implementing programmes to maximise the chance of successful implementation and minimise the possibility of wasting resources through poor and non-evidence-based implementation.

Citation and Funding

Pearson M, Chilton R, Wyatt K, et al. Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom. Implement Sci. 2015;10(1):149.

This project was funded by the National Institute for Health Research, School for Public Health Research.

Bibliography

NICE. Preventing excess weight gain. NG7. London: National Institute for Health and Care Excellence; 2015.

NICE. Oral health: local authorities and partners. PH55. London: National Institute for Health and Care Excellence; 2014.

NICE. Smoking prevention in schools. PH23. London: National Institute for Health and Care Excellence; 2010.

NICE. Physical activity for children and young people. PH17. London: National Institute for Health and Care Excellence; 2009.

NICE. Social and emotional wellbeing in primary education. PH12. London: National Institute for Health and Care Excellence; 2008.

NICE. Social and emotional wellbeing in secondary education. PH20. London: National Institute for Health and Care Excellence; 2009.

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

Why was this study needed?

The risk of developing many common diseases in the UK can be lowered by making lifestyle changes. For example, reducing salt intake to reduce the risk of heart disease or maintaining a healthy weight to reduce the risk of diabetes.

Many suggest that promoting healthy lifestyle choices – health promotion – should start early in life to help establish healthy habits early and prevent disease, rather than trying to reverse unhealthy habits later in life, or once illness had occurred. As such, school is recognised by NICE as an important setting for improving various aspects of health promotion, such as preventing excess weight gain, improving oral health and reducing smoking and alcohol use.

This review investigated the factors that contributed to successful or unsuccessful implementation of UK school-based health promotion programmes.

What did this study do?

This was a “realist” review – meaning it focused on the implementation of interventions, rather than their effectiveness. The first part of the review used 22 UK-based studies (some funded by NIHR) to produce a framework of the different aspects of implementation, known as “programme theories”. These programme theories were then tested and refined using a further 41 studies. Data were extracted until “theoretical saturation”, the point at which adding new studies is considered unlikely to yield further insight. Studies were also critically appraised so that the authors could indicate the quality of the evidence underlying their findings.

What did it find?

  • The review identified four “programme theories” affecting implementation success: preparing for implementation, introducing a programme within a school, embedding a programme into routine practice, and fidelity of implementation (how closely the reality matched the intention) and programme adaptation.
  • Preparing. Integration was more likely to be successful when systematically planned in line with the school’s existing responsibilities. This involved pre-delivery consultation. New or contentious programmes may need more consultation than well-established or uncontentious programmes. Pupils need to understand the relevance and benefits, and teachers and pupils need to feel supported. The authors identified the notion of reciprocity, with both teachers and pupils needing clear benefits (including non-health advantages, such as developing transferable skills) to participate. The new programme should be fitted in with current school activities.
  • Introducing. Successful implementation was more likely if health promotion programmes are integrated into the life of the school. This can be achieved through appropriate senior level support, a named co-ordinator showing leadership, and positive engagement with teachers, public and others involved in the programme delivery or participation.
  • Embedding. There was limited evidence informing how to best embed a programme into routine practice.
  • Implementing. Limited evidence also informed best approaches to ensure fidelity – i.e. how closely the programme stuck to the original aims. But elements to consider were around programme adaptation, and the elements of the programme that are essential, optional and adaptable by those delivering it.

What does current guidance say on this issue?

NICE guidelines relating to health promotion programmes in schools cover: alcohol interventions (PH7), physical activity for children and young people (PH17), smoking prevention in schools (PH23) and social and emotional wellbeing in primary education (PH12) and secondary education (PH20). Where implementation advice is provided, it reflects the findings of this review. For example, using a “whole school” approach to embed programmes into the school, family and wider community – such as in the case of oral health programmes (2014), smoking prevention (2010) and alcohol consumption (2007).

What are the implications?

The focus in research can often – and understandably – be on the effectiveness of an intervention, rather than how it can be best implemented in different contexts. Both are important for success. This review suggests implementation issues to consider when selecting and planning the implementation of health promotion programmes in schools. For instance, it may be helpful to identify which parts of a programme are standard and which could be adapted to fit the needs of local schools. The “programme theories” developed in this review should be considered by those implementing programmes to maximise the chance of successful implementation and minimise the possibility of wasting resources through poor and non-evidence-based implementation.

Citation and Funding

Pearson M, Chilton R, Wyatt K, et al. Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom. Implement Sci. 2015;10(1):149.

This project was funded by the National Institute for Health Research, School for Public Health Research.

Bibliography

NICE. Preventing excess weight gain. NG7. London: National Institute for Health and Care Excellence; 2015.

NICE. Oral health: local authorities and partners. PH55. London: National Institute for Health and Care Excellence; 2014.

NICE. Smoking prevention in schools. PH23. London: National Institute for Health and Care Excellence; 2010.

NICE. Physical activity for children and young people. PH17. London: National Institute for Health and Care Excellence; 2009.

NICE. Social and emotional wellbeing in primary education. PH12. London: National Institute for Health and Care Excellence; 2008.

NICE. Social and emotional wellbeing in secondary education. PH20. London: National Institute for Health and Care Excellence; 2009.

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

Published on 30 October 2015

Pearson, M.,Chilton, R.,Wyatt, K.,Abraham, C.,Ford, T.,Woods, H. B.,Anderson, R.

Implement Sci Volume 10 , 2015

BACKGROUND: Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children's and young people's health. However, understanding of how such programmes can be implemented in schools is more limited. METHODS: We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset. RESULTS: In consultation with the review advisory group, we developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity-the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited. CONCLUSIONS: Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Expert commentary

The realist systematic review provides a useful methodology for front line practitioners to gain an understanding of developing and delivering health promotion in schools. The paper underscores the themes that enable successful delivery of any project including careful planning and engagement with stakeholders. There is emphasis on the need for extensive engagement with parents, young people, teachers, school nurses and other stakeholders where the course content is contentious, for example in PSHE. The paper provides a sound theoretical starting point for those delivering health promotion in schools.

The synthesis of the projects examined in the paper shows a lack of focus on sustainability and learning outcomes (intended and unintended) and underscores the need to “start with the end in mind” when planning health promotion projects including planning for evaluation and ensuring the content is accessible and inclusive.

Jill Beswick, Chair, School and Public Health Nurses Association

Expert commentary

There is compelling evidence of the effects of school health promotion on young people’s health, but limited evidence regarding the implementation of such programmes. I particularly found the initial implementation phase of great interest, and also the inclusion regarding the ethos of reciprocity helpful. It would certainly merit further research regarding the embedding and sustaining elements of the overall implementation, as identified by the author for further research. The specialist community public health nurse (school nursing) has a role to play here by working in partnership with education staff and with future researchers, as their expertise lies in early intervention and prevention strategies, and how to sustain such strategies as well as deliver them.

Gill Treverton, Senior Tutor in Specialist Community Public Health Nursing, University Of Bedforshire