The effects of the school environment on student health: A systematic review of multi-level studies
highlights
► Health outcomes vary between schools; possibly attributable to the institutional environment. ► Evidence from existing reviews is limited due to weaknesses in review or study methodology. ► We reviewed multi-level studies examining the health effects of the school environment. ► Searches yielded 82775 references; 42 were included; 10 were of sufficient quality to synthesize. ► Schools with higher than expected attainment/attendance had lower rates of risk behaviours.
Introduction
Disparities in health are often shaped early in life during childhood and adolescence and sustained across the life course. Investing in early years therefore is vital to reducing health inequalities (Marmot, 2010). Health education delivered through the school curriculum and aiming to improve knowledge, develop skills and modify norms is now well-established in schools, addressing substance use, sexual behaviour, physical activity and diet. However, such interventions often have disappointing results (DiCenso et al., 2002, Faggiano et al., 2005, Foxcroft et al., 2002, Harden et al., 2001, Oliver et al., 2008, Thomas and Perera, 2006, Wells et al., 2003). A complementary approach is to modify the school environment to promote health, informed by the notion of ‘school effects’.
Originating with the work of Rutter et al. (1979), educational researchers have found that a school's ethos, in terms of values, attitudes and organisation can explain differences in attainment and behaviour between schools (Arnot et al., 1998, Gaine and George, 1999, Gripps and Murphy, 1994, MacBeath and Mortimore, 2001, Scheerens, 2000). According to Macintyre et al. (2002), the effects of place on health can occur due to both ‘compositional’ (which people are found in a place) and ‘contextual’ factors (the characteristics of a place). Rutter's seminal work on ‘school effects’ prompted further research to examine if certain institutional-level characteristics also influenced students’ health-related behaviours (West, 2006).
In their theory of human functioning and school organisation, Markham and Aveyard (2003) suggested that to enable young people to choose health-promoting behaviours, schools should develop students’ ‘practical reasoning’ (ability to understand one's own and others' perspectives and emotions) and sense of ‘affiliation’ (ability to form relationships). A school is theorised to enable students to fulfil these capacities through its ‘instructional’ and ‘regulatory’ orders, which, respectively, promote learning and behavioural norms. Students committed to these orders are more likely to choose healthy behaviours, whereas students disconnected from one or both orders are more likely to seek affiliation in anti-school peer groups and risk behaviours such as smoking. Schools’ abilities to build commitment is theorised as depending on how flexibly they define ‘boundaries’, for example between staff and students, and how student-centred is the organisation and delivery (‘framing’) of schooling.
Existing syntheses have not been able to examine Markham and Aveyard's theory. An early review of the effects of anti-smoking policies on student smoking was hampered by its non-systematic design and inclusion of ecological studies alongside multi-level studies (Evans-Whipp et al., 2004). Multi-level studies, unlike ecological studies, enable proper examination of how features of the school as an institution as opposed to the compositional features of the student body affect student health outcomes. A review of school effects on smoking by Aveyard et al. (2004a) acknowledged the importance of multi-level evidence, but found few studies. It concluded that although smoking prevalence differed markedly between schools, it was not yet possible to determine whether this reflected compositional or institutional factors. This was because studies did not adequately adjust for the potentially confounding effects of families and neighbourhoods, or over-adjusted for factors which might actually mediate school-level effects on smoking, such as student attitudes to school and peer behaviours, so that it is impossible to determine for example whether null effects reflect an absence of school effects or that these are present but are mediated by factors for which adjustment is made. Another review of multi-level studies of school effects on a range of student outcomes did not involve systematic methods (Sellström and Bremberg, 2006). Reviews of school effects on drug use (Fletcher et al., 2008) and students’ emotional health outcomes (Kidger et al., 2012) have included longitudinal studies examining individual-level measures of schooling alongside multi-level studies and do not fully examine whether the latter took an appropriate approach to confounding. Previous reviews have also included studies that rely on the same sources for data on school-level determinants and health outcomes; for example studies using school-level measures derived from aggregates of self-reports from the same individuals (usually students) providing outcome data. This can introduce ‘same-source’ bias whereby any associations found might merely reflect unmeasured characteristics of those providing the data (Duncan and Raudenbush, 1999). For example, students who are more likely to report negative relationships in school might also be more likely to report engagement in health risks.
Considering these limitations, we conclude a systematic review of multi-level studies of school health effects focused on studies which appropriately adjust for covariates and are not subject to same-source bias is now timely. Our review was done as part of a larger project mapping and synthesising evidence on how the school environment influences health (Bonell et al., 2011). In stage 1 of the project, we identified and descriptively mapped a broad array of literature on how the school environment may influence staff and student health. This map was then presented to academic, policy and youth stakeholders with whom we consulted to help define priorities for the second stage of the review.
In stage 2, we focused on student health and defined school environment more narrowly in terms of school organisation/management, teaching, pastoral care, discipline and/or physical environment. We chose not to focus on catering or physical exercise lessons because these areas are already well synthesised (Dobbins et al., 2009, Shepherd et al., 2001). Stage 2 involved several in-depth reviews, of which the review of multi-level studies reported here was undertaken to address the question: what are the effects of school-level measures of the environment (defined as above) on health and health inequalities among school students aged 4–18 years examined via multi-level quantitative designs?
Section snippets
Methods
Following a protocol (Bonell et al., 2011), in stage 1 we mapped references of articles judged as theorising or empirically examining: the influence on staff or student (aged 4–18) health of the school social and/or physical environment; interventions to address this (not including the provision of health education or health-related goods or services); and/or the processes underlying these. Sixteen bibliographic databases were searched between 30 July and 23 September 2010, with no limits on
Results
Database searches retrieved 82,775 references, of which 20,446 were duplicates. The remaining 62,329 references were screened on title and abstract, so that 1144 references were mapped (map available on request). Of the 285 references identified as ecological or multi-level studies in the evidence map, 236 were excluded based on the criteria in Fig. 1. In addition, five reports were duplicates and the full texts were not available for six. Studies that were excluded because they drew on
Discussion
We identified 42 reports of multi-level studies of school-level health effects (from 34 datasets) where school-level measures drew on different information sources than health outcomes. We confined our narrative synthesis of results to 10 studies which appropriately adjusted for covariates. These studies addressed some aspects of our research question more than others. In terms of school-level influences: the studies of value-added education are intended as indicators of teaching and of
Acknowledgments
We would like to thank Val Hamilton, Carol Vigurs, Jeff Brunton, Sergio Graziosi, Alison O′Mara-Eves and Juan Daniel Kennedy for their contribution to the project. This project was funded by the National Institute for Health Research Public Health Research (NIHR PHR) Programme (project number 09/3002/08). Visit the PHR Programme website for more information. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the PHR Programme, NIHR, NHS or
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