Abstract
BackgroundSchools 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.MethodsWe 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.ResultsIn 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.ConclusionsOur findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0338-6) contains supplementary material, which is available to authorized users.
Highlights
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
We chose to conduct a realist review in order to attain a contextualised understanding of how and why complex interventions achieve particular effects—in realist terminology, how mechanisms lead to outcomes in particular contexts [18, 19]
We have extended the work of Greenberg et al [32] and Samdal and Rowling [5] by moving beyond statements about the principles of good implementation practice and towards a more refined understanding of the complexity of implementation within educational, public health, and social systems that are constrained in multiple, setting-specific ways
Summary
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 about the contribution that comprehensive, integrated approaches to health promotion in schools can make to improving children’s and young people’s health in a number of areas [9, 10]. Understanding of how these effects are attained is increasing [11]. The reality of implementing health promotion programmes in schools involves the active engagement of a range of actors [13, 14] and the adaptation of programmes to local contexts [15, 16] within a wider educational and public health system They can be considered as complex interventions (multi-component, contextsensitive, and highly dependent on the behaviours of participants and providers) within a complex system [17]
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