Changing school climates to promote adolescent wellbeing: two trials with one goal
Authors: Shanthi Ameratunga, Terryann Clark, Prerna Banati
Journal: The Lancet (2018)

It is easy to use the word “unprecedented” when reviewing recent statistics about young people. We have the largest generation of adolescents in human history, their prospects for formal education are escalating, and previously tenacious disparities in school attendance between boys and girls are dwindling.1UNESCOGlobal Education Monitoring Report 2017/2018 - Accountability in Education: Meeting our Commitments. United Nations Educational, Scientific and Cultural Organization, Pars2017Google Scholar From 1985 to 2016, the proportion of young people enrolled in secondary schools increased from an estimated 47% to 76%.2World BankSecondary school enrolment – data from the UNESCO Institute for Statistics.https://data.worldbank.org/indicator/SE.SEC.ENRR?view=chartDate: 2018Date accessed: August 20, 2018Google Scholar Schools are consequently increasingly accessible for learning and socialisation. Yet a UNICEF report published in 2018 notes: “For millions of students around the world, the school environment is not a safe space to study and grow.”3UNICEFAn Everyday Lesson: #ENDviolence in Schools. Division of Communication, Programme Division/Child Protection and Education, New York2018Google Scholar The authors estimate that approximately 150 million 13–15-year-old students experience peer-to-peer violence in and around school, with at least a third of students being bullied in the previous month and a third involved in physical fights in the previous 12 months.3UNICEFAn Everyday Lesson: #ENDviolence in Schools. Division of Communication, Programme Division/Child Protection and Education, New York2018Google Scholar As environments where students, teachers, parents, and communities can come together, schools are fertile settings to address these negative experiences, which often have lifelong consequences.3UNICEFAn Everyday Lesson: #ENDviolence in Schools. Division of Communication, Programme Division/Child Protection and Education, New York2018Google Scholar, 4Menesini E Salmivalli C Bullying in schools: the state of knowledge and interventions.Psychol Health Med. 2017; 22: 240-253Crossref PubMed Scopus (288) Google Scholar, 5Leschied AW Saklofske DH Flett GL Handbook of School-based Mental Health Promotion: An Evidence-informed Framework for Implementation. Springer, Cham, Switzerland2018Crossref Google Scholar However, schools are often reluctant to divert resources from education to wider social influences, and experimental evidence linking such efforts with improved adolescent health is sparse.6Aldridge JM McChesney K The relationships between school climate and adolescent mental health and wellbeing: A systematic review.Intl J Edu Res. 2018; 88: 121-145Crossref Scopus (145) Google Scholar, 7Milfont TL Denny SJ Everyday environments and quality of life: positive school and neighborhood environments influence the health and well-being of adolescents.in: Fleury-Bahi G Pol E Navarro O Handbook of Environmental psychology and quality of life research. Springer International Publishing, Switzerland2017: 369-384Crossref Google Scholar The two cluster-randomised controlled trials reported by Sachin Shinde and colleagues8Shinde S Weiss HA Varghese B et al.Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial.Lancet. 2018; (published online Nov 22.)http://dx.doi.org/10.1016/S0140-6736(18)31615-5Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar and Chris Bonell and colleagues9Bonell C Allen E Warren E et al.Effects of the Learning Together intervention on bullying and aggression in English secondary schools (INCLUSIVE): a cluster randomised controlled trial.Lancet. 2018; (published online Nov 22.)http://dx.doi.org/10.1016/S0140-6736(18)31782-3Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar in The Lancet are highly salient in this context. Done in two very different settings (India and the UK), both trials used rigorous public health and youth engagement strategies to change the overall school climate (rather than individual behaviour change) and found remarkably similar effects on students' health and wellbeing. Shinde and colleagues8Shinde S Weiss HA Varghese B et al.Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial.Lancet. 2018; (published online Nov 22.)http://dx.doi.org/10.1016/S0140-6736(18)31615-5Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar evaluated the SEHER intervention involving whole school, classroom, and individual activities directed at grade 9 students (mean age 13 years) in 74 government-run schools in the state of Bihar, India. Relative to students in control schools receiving standard state-wide adolescent education, students in schools where the intervention was delivered by lay counsellors reported substantial benefits to the overall school climate, assessed by the Beyond Blue School Climate Questionnaire. The baseline-adjusted mean difference was 7·57 (95% CI 6·11–9·03) compared with the control group. The investigators also reported reductions in bullying, violence, symptoms of depression, and smoking; and improved sexual health knowledge and attitudes towards gender equity. These benefits were not evident in the group in which teachers delivered the intervention. The INCLUSIVE trial,9Bonell C Allen E Warren E et al.Effects of the Learning Together intervention on bullying and aggression in English secondary schools (INCLUSIVE): a cluster randomised controlled trial.Lancet. 2018; (published online Nov 22.)http://dx.doi.org/10.1016/S0140-6736(18)31782-3Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar involving 40 schools in southeast England, evaluated the Learning Together intervention, a whole-school programme incorporating restorative practice commencing in year 7 (11–12-year-olds). Compared with the control group, who were exposed to usual practice, students in the intervention group were less likely to report bullying (as measured by the Gatehouse Bullying Scale at 3 years; adjusted mean difference −0·03, 95% CI −0·06 to −0·001), although there was no effect on aggression (assessed by the Edinburgh Study of Youth Transitions and Crime score; adjusted mean difference −0·13, −0·43 to 0·18). They noted improvements in smoking, drinking alcohol, drug use, and police contact. They also reported better quality of life, and psychological and general wellbeing. Many intervention effects were stronger among students with higher baseline levels of bullying. However, the benefits were evident only in the third year of the study and not earlier, indicating the need for long-term investments that provide time to embed interventions within school procedures. The novel insights from these studies have several implications. First, the positive findings from these relatively low-cost interventions are heartening given the increasing demand for evidence-based approaches to promote adolescent wellbeing. The similar effects of the two interventions targeting the same factor (school climate) in very different settings also supports the generalisability of the findings. However, it would be useful to replicate these studies in other contexts and address place-based factors within and outside school.10Ebersohn L Making sense of place in school-based intervention research.Contemp Edu Psychol. 2015; 40: 121-130Crossref Scopus (8) Google Scholar Could these approaches be effective in low performing schools (excluded from the INCLUSIVE trial)? And could they improve school attendance (relatively low in the Bihar study, at 50·7%)? Second, the effective intervention arms in both studies engaged external facilitators. Using teachers to deliver the intervention reduces costs, but their other responsibilities (eg, giving assessments or disciplining students), prevailing power dynamics, and work pressures could undermine the ethos of these interventions. A survey done in England found that 93% of teachers and school leaders viewed their workload as a “very” or “fairly” serious problem.1UNESCOGlobal Education Monitoring Report 2017/2018 - Accountability in Education: Meeting our Commitments. United Nations Educational, Scientific and Cultural Organization, Pars2017Google Scholar In low-income settings where secondary education is being scaled up quickly and infrastructure more constrained, teachers could find the implementation of extracurricular interventions particularly challenging. A passionate well-trained layperson could be more influential and less threatening in changing students' and teachers' practices. This option raises implications for resourcing. With schools increasingly employing nurses, social workers, and school counsellors, is there potential to employ youth workers, health promoters, or cultural support workers to enhance school wellbeing? Could these non-teaching staff lose their ability to challenge the status quo in schools if they become internal employees with teachers as their managers? Careful negotiation of these roles and management will be needed to ensure the legitimacy of their roles as part of the school environment while maintaining their independence and ability to challenge. Third, there are several aspects that require further development and evaluation. For example, can the programme be enhanced to improve areas that were relatively resistant to change—eg, aggressive behaviours and perpetration of bullying in the INCLUSIVE trial? What might explain the different effects by gender in these trials, and to what extent might intervention effects vary by age, ethnicity, religion, or other differences? Finally, some school health promotion messages can appear incongruous, and be less effective, in the context of wider societal norms. About 720 million school-aged children live in countries where corporal punishment at school is not fully prohibited.3UNICEFAn Everyday Lesson: #ENDviolence in Schools. Division of Communication, Programme Division/Child Protection and Education, New York2018Google Scholar Although they found favourable effects on drinking, the investigators of the INCLUSIVE trial suggest that the lack of effect on sexual health could be due to these behaviours typically occurring outside school. The difficulties in improving sexual health might lie in social taboos and cultural norms that prevent open and honest discussions with adolescents about relationships, consent, and safer sexual behaviour without resorting to shaming or use of scare tactics. Notwithstanding issues that require further attention, both trials provide compelling evidence to target investments and resources to enhance school environments as a social determinant of health amenable to modification. We declare no competing interests. Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trialThe multi-component whole-school SEHER health promotion intervention had substantial beneficial effects on school climate and health-related outcomes when delivered by lay counsellors, but no effects when delivered by teachers. Future research should focus on the evaluation of the scaling up of the SEHER intervention in diverse contexts and delivery agents. Full-Text PDF Effects of the Learning Together intervention on bullying and aggression in English secondary schools (INCLUSIVE): a cluster randomised controlled trialLearning Together had small but significant effects on bullying, which could be important for public health, but no effect on aggression. Interventions to promote student health by modifying the whole-school environment are likely to be one of the most feasible and efficient ways of addressing closely related risk and health outcomes in children and young people. Full-Text PDF Open Access