The Moderating Role of the School Context on the Effects of the Healthy Primary School of the Future

Background: The current study investigated the moderating role of the school context on the effects of a Dutch health promoting school initiative on children’s health and health behaviors. Methods: The study used a mixed-methods design. The school context (n = 4) was assessed by the characteristics of the school population, teacher’s health-promoting (HP) practices, implementers’ perceived barriers, school’s HP elements, and dominating organizational issues. Outcomes included objectively assessed BMI z-scores and physical activity (PA), and parent and child-reported dietary intake. Analyses included linear mixed models (four intervention schools versus four control schools), and qualitative comparisons between intervention schools with similar HP changes. Results: Effects on outcomes varied considerably across schools (e.g., range in effect size on light PA of 0.01–0.26). Potentially moderating contextual aspects were the child’s socioeconomic background and baseline health behaviors; practices and perceived barriers of employees; and organizational issues at a school level. Conclusions: Similar HP changes lead to different outcomes across schools due to differences in the school context. The adoption of a complex adaptive systems perspective contributes to a better understanding of the variation in effects and it can provide insight on which contextual aspects to focus on or intervene in to optimize the effects of HP initiatives.

[1]  Promoting health through schools. Report of a WHO Expert Committee on Comprehensive School Health Education and Promotion. , 1997, World Health Organization technical report series.

[2]  M. Deschesnes,et al.  Comprehensive approaches to school health promotion: how to achieve broader implementation? , 2003, Health promotion international.

[3]  Fadhel Kaboub.  Realistic Evaluation , 2004 .

[4]  M. Jansen,et al.  Development of a collaborative model to improve school health promotion in The Netherlands. , 2005, Health promotion international.

[5]  V. Shavers.  Measurement of socioeconomic status in health disparities research. , 2007, Journal of the National Medical Association.

[6]  D. Lohrmann.  A Complementary Ecological Model of the Coordinated School Health Program , 2008, Public health reports.

[7]  R. Mcmurray,et al.  Calibration of two objective measures of physical activity for children , 2008, Journal of sports sciences.

[8]  D. McFarland,et al.  Global Perspectives on Health Promotion Effectiveness , 2008 .

[9]  L. Potvin,et al.  Exploring the Intervention— Context Interface , 2009 .

[10]  Blake Poland,et al.  Settings for Health Promotion: An Analytic Framework to Guide Intervention Design and Implementation , 2009, Health promotion practice.

[11]  Albert Lee,et al.  Health-promoting schools , 2009, Applied health economics and health policy.

[12]  Alan Shiell,et al.  Theorising Interventions as Events in Systems , 2009, American journal of community psychology.

[13]  J. Lowery,et al.  Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science , 2009, Implementation science : IS.

[14]  Kevin Fiscella,et al.  Disparities in Academic Achievement and Health: The Intersection of Child Education and Health Policy , 2009, Pediatrics.

[15]  Michael Quinn Patton,et al.  Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use , 2010 .

[16]  Don Nutbeam,et al.  Schools as social complex adaptive systems: a new way to understand the challenges of introducing the health promoting schools concept. , 2010, Social science & medicine.

[17]  H. Hartwell.  Healthy settings. , 2010, Perspectives in public health.

[18]  Stef van Buuren,et al.  Increase in Prevalence of Overweight in Dutch Children and Adolescents: A Comparison of Nationwide Growth Studies in 1980, 1997 and 2009 , 2011, PloS one.

[19]  E. Waters,et al.  The WHO Health Promoting School framework for improving the health and well‐being of students and staff , 2011 .

[20]  M. Suhrcke,et al.  The impact of health and health behaviours on educational outcomes in high-income countries: a review of the evidence. , 2011 .

[21]  C. Burton.  Heavy Tailed Distributions of Effect Sizes in Systematic Reviews of Complex Interventions , 2012, PloS one.

[22]  Peter Tugwell,et al.  What types of interventions generate inequalities? Evidence from systematic reviews , 2012, Journal of Epidemiology & Community Health.

[23]  Ligia Paina,et al.  Understanding pathways for scaling up health services through the lens of complex adaptive systems. , 2012, Health policy and planning.

[24]  M. Petticrew,et al.  The effects of the school environment on student health: a systematic review of multi-level studies. , 2013, Health & place.

[25]  S. Verweij.  Set-theoretic methods for the social sciences: a guide to qualitative comparative analysis , 2013 .

[26]  Sean Snyder,et al.  The Simple, the Complicated, and the Complex: Educational Reform Through the Lens of Complexity Theory , 2013 .

[27]  Peter S. Hovmand,et al.  Introduction to Community-Based System Dynamics , 2014 .

[28]  S. Kremers,et al.  The next step in health behavior research: the need for ecological moderation analyses - an application to diet and physical activity at childcare , 2014, International Journal of Behavioral Nutrition and Physical Activity.

[29]  Deborah I Thompson,et al.  Psychometrics of the preschooler physical activity parenting practices instrument among a Latino sample , 2014, International Journal of Behavioral Nutrition and Physical Activity.

[30]  S. van Buuren,et al.  Towards a measurement instrument for determinants of innovations , 2014, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[31]  Heather Kane,et al.  Using qualitative comparative analysis to understand and quantify translation and implementation , 2014, Translational behavioral medicine.

[32]  E. Waters,et al.  The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. , 2014, The Cochrane database of systematic reviews.

[33]  P. van Assema,et al.  Patterns of Food Parenting Practices and Children’s Intake of Energy-Dense Snack Foods , 2015, Nutrients.

[34]  S. Kremers,et al.  Use of Food Practices by Childcare Staff and the Association with Dietary Intake of Children at Childcare , 2015, Nutrients.

[35]  A. O’Cathain,et al.  Process evaluation of complex interventions: Medical Research Council guidance , 2015, BMJ : British Medical Journal.

[36]  K. Ball.  Traversing myths and mountains: addressing socioeconomic inequities in the promotion of nutrition and physical activity behaviours , 2015, International Journal of Behavioral Nutrition and Physical Activity.

[37]  Karien M. Coppens,et al.  The Healthy Primary School of the Future: study protocol of a quasi-experimental study , 2016, BMC Public Health.

[38]  D. Jourdan,et al.  Health Promoting Schools-a complex approach and a major means to health improvement. , 2017, Health promotion international.

[39]  Scott R. Rosas,et al.  Systems thinking and complexity: considerations for health promoting schools , 2015, Health promotion international.

[40]  D. Jourdan,et al.  Implementation of health promotion programmes in schools: an approach to understand the influence of contextual factors on the process? , 2018, BMC Public Health.

[41]  P. van Assema,et al.  The Comprehensive Snack Parenting Questionnaire (CSPQ): Development and Test-Retest Reliability , 2018, International journal of environmental research and public health.

[42]  Effect in zijn context , 2018, Tijdschrift voor gezondheidswetenschappen.

[43]  S. Kremers,et al.  Measuring implementation fidelity of school-based obesity prevention programmes: a systematic review , 2018, International Journal of Behavioral Nutrition and Physical Activity.

[44]  H. Bosma,et al.  Socioeconomic multi-domain health inequalities in Dutch primary school children , 2018, European journal of public health.

[45]  H. Savelberg,et al.  The Healthy Primary School of the Future: A Contextual Action-Oriented Research Approach , 2018, International journal of environmental research and public health.

[46]  H. Savelberg,et al.  Process evaluation of the healthy primary School of the Future: the key learning points , 2019, BMC Public Health.

[47]  H. Savelberg,et al.  One- and Two-Year Effects of the Healthy Primary School of the Future on Children’s Dietary and Physical Activity Behaviours: A Quasi-Experimental Study , 2019, Nutrients.

[48]  C. Bonell,et al.  From complex social interventions to interventions in complex social systems: Future directions and unresolved questions for intervention development and evaluation , 2018, Evaluation.

[49]  H. Savelberg,et al.  Can the Healthy Primary School of the Future offer perspective in the ongoing obesity epidemic in young children? A Dutch quasi-experimental study , 2019, BMJ Open.