Opportunities and solutions: addressing health in schools

Schools offer a unique environment from which to support adolescents in developing good physical and mental health, establishing behaviours to prevent future health problems, and effectively managing existing conditions. Many countries have attempted to capitalise on this opportunity, with school-based or school-linked service provision in at least 102 countries.^1,2 The relationship between schools and health goes in both directions: schools are important for improving students’ health, and students’ health is important for improving their educational outcomes.³

A “Health Promoting Schools” approach was developed by the World Health Organization and others in the 1990s, in which health is promoted through the whole school environment as well as through health education in classrooms and partnerships with parents or the wider community.⁴ In 2000, a further initiative, the Focusing Resources on Effective School Health (FRESH) framework was launched by international agencies to develop effective school health policies, programmes, and services.⁵ These initiatives focus on 4 core components, or pillars:

• health-related school policies;
• safe water & sanitation;
• skills-based health education; and
• access to health & nutrition services.

In line with these initiatives, examples of adolescent health issues which can be addressed in schools in low-resource countries include: programmes for the prevention of violence and unintentional injury; school feeding; deworming; iron-folate supplementation; HPV and tetanus vaccination; weight and height measurement; handwashing; and menstrual health interventions. Programmes for the prevention of non-communicable diseases (NCDs), mainly in high-resource countries include: programmes on physical activity; healthy eating (increasing vegetable and fruit intake, control of sugar and fat intake); mental health and well-being; oral health; and alcohol, tobacco, and substance use. Different models can be used to implement these strategies, such as the school nurse model used in the UK, and mobile health teams that move between schools in South Africa.^6,7 However, implementation of these programmes can be weak due to challenges with co-ordination, resources, and referral strategies.⁷

A systematic review of reviews of school-based interventions to promote adolescent health found that multicomponent school-based interventions including school policy changes, parent involvement, and work with local communities can be effective for improving school climate and preventing bullying.⁸ For example, a recent cluster-randomised trial from Bihar State in government-run secondary schools in India compared the addition of a multi-component whole-school health promotion intervention by lay counsellors with the same intervention delivered by teachers, and with the standard Government-run life-skills intervention only.⁹ The trial found that the lay-counsellor-delivered intervention had substantial beneficial effects on school climate and on a range of health-related outcomes including depressive symptoms, bullying, violence, attitude towards gender equity, and knowledge of reproductive and sexual health, compared with both the Government standard life skills intervention on its own and the teacher-delivered intervention.⁹ A similar trial in English secondary schools which included a school action group and a student social- and emotional-skills curriculum found small but significant effects on bullying, but no effect on aggression.¹⁰

Studies in the United States have indicated that multi-component interventions can reduce teenage pregnancy and risky sexual behaviours.^11,12 However, there is less evidence from other countries so generalizability is uncertain. Economic incentives to young people or the wider community may also be effective in increasing age at marriage as well as conception and total fertility rates.¹³ Multicomponent school-based interventions can also reduce smoking.^14,15 In contrast, there is little evidence that such interventions can reduce alcohol and drug use.⁸ This may be because these behaviours mostly occur outside schools or simply reflect the paucity of relevant studies. The review also concluded there was evidence of effectiveness for increasing physical activity and fruit and vegetable intake, and reducing the incidence of being bullied, as well as evidence of promise for reducing violence, bullying others, and increasing handwashing, but insufficient evidence to draw any conclusions for the potential impact on mental health and sexual health.⁸

There is currently relatively little evidence for the effectiveness of other types of school health interventions, such as peer-delivered interventions, school-based clinics, and individual counselling interventions although these are currently active areas of research. For example, a recently published study found that a peer-delivered school-based intervention can reduce substance use.⁸

Overall, key factors for implementing school health programmes successfully with limited human and financial resources include: strengthening collaboration among all stakeholders including the head-teacher, students, parents, teachers, and policy-makers; better costing; ensuring long-term financing for plans and procedures; and promoting a comprehensive health education approach.

In conclusion, schools provide a potential context for improving the health of older children and adolescents, especially given the recent increases in global school attendance, and there is increasing evidence that interventions to make schools more health promoting can be effective. More research is needed to establish how best to make use of the potential resource for health that is provided by schools. Already, programmes can build on what is currently known to implement evidence-based interventions within the four key pillars of a health promoting school.^4,5,16