Abstract
BackgroundThe sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. If effective interventions discontinue, new practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? What are the barriers and facilitators affecting the sustainability of public health interventions in schools in high-income countries?MethodsSeven bibliographic databases and 15 websites were searched. References and citations of included studies were searched, and experts and authors were contacted to identify relevant studies. We included reports published from 1996 onwards. References were screened on title/abstract, and those included were screened on full report. We conducted data extraction and appraisal using an existing tool. Extracted data were qualitatively synthesised for common themes, using May’s General Theory of Implementation (2013) as a conceptual framework.ResultsOf the 9677 unique references identified through database searching and other search strategies, 24 studies of 18 interventions were included in the review. No interventions were sustained in their entirety; all had some components that were sustained by some schools or staff, bar one that was completely discontinued. No discernible relationship was found between evidence of effectiveness and sustainability. Key facilitators included commitment/support from senior leaders, staff observing a positive impact on students’ engagement and wellbeing, and staff confidence in delivering health promotion and belief in its value. Important contextual barriers emerged: the norm of prioritising educational outcomes under time and resource constraints, insufficient funding/resources, staff turnover and a lack of ongoing training. Adaptation of the intervention to existing routines and changing contexts appeared to be part of the sustainability process.ConclusionsExisting evidence suggests that sustainability depends upon schools developing and retaining senior leaders and staff that are knowledgeable, skilled and motivated to continue delivering health promotion through ever-changing circumstances. Evidence of effectiveness did not appear to be an influential factor. However, methodologically stronger primary research, informed by theory, is needed.Trial registrationThe review was registered on PROSPERO: CRD42017076320, Sep. 2017.
Highlights
The sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care
As the resources available to schools will likely impact on sustainability, we focus on high-income countries only
Data extraction was completed for these 24 studies; extraction was not conducted on three doctoral theses [40–42] because each had a corresponding published paper of the same study included in the review [43–45]
Summary
The sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. New practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? While there has been progress in assessing the effectiveness of such interventions [9–11], and factors affecting implementation [12–14], there is less evidence about sustaining health interventions in schools beyond initial pilots. New practices cannot reach wider populations and investments in time, people and resources to initiate and implement them may be wasted [15–18]. Factors suggested as promoting sustainability include intervention effectiveness, attributes and cost [15, 17, 24]; practitioners’ attributes and activities [21, 24]; the work of intervention champions and organisational leaders [25, 26]; organisational climate and culture; monitoring and evaluation; staff turnover [25, 27]; and the external political and financial climate [26]
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