Viewpoint
Supporting every school to become a foundation for healthy lives

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Summary

As a setting where children and adolescents live and learn, linked to the family and embedded within the wider community, schools have an important influence on every student's health. Many health interventions have used schools as a platform, often for standalone programmatic initiatives to reduce health risks, and sometimes for more comprehensive approaches, but the interventions, uptake, and sustainability are generally disappointing. Evidence shows that, to improve health and to reduce inequality, all students must attend school from a young age and for as long as possible, and their educational success therein must be maximised. Thus, beyond educational benefits, schools are also important for health. Coherence between each school's policies, structures and systems, human resources, and practices is required to advance both academic and health outcomes. Beyond simply implementing ready-made programmes into schools, health professionals can position themselves as catalysts for structural change as they have many opportunities to advocate for, and participate in, the intersectoral implementation of reforms and innovations in school systems to promote the health of all students.

Introduction

The health of children and adolescents is influenced by a complex interplay of biopsychosocial, cultural, environmental, and economic factors.1 As an educational setting where children and adolescents spend a large proportion of their daily lives, school has an important influence on every student's health and wellbeing.2 Simply attending school for longer is associated with better health outcomes, including intergenerational benefits—eg, mothers who are better educated typically have healthier children than mothers who have received less education.3 We have known for more than a century that the provision of healthy food and social support at school improves attendance and increases participation in children and adolescents from disadvantaged communities.4 Globally, growing rates of school participation mean that schools are increasingly recognised as an important platform for enhancing student health, with different formal and informal mechanisms by which these health benefits can occur.5 However, there is substantial tension between the aspiration of the health sector to deliver discrete, programmatically based interventions on a range of health topics (such as nutrition, sexuality, parasite eradication, or vaccinations) with more systemic approaches that are required to influence school policies and practices, reshape environments, and build wider community partnerships that underpin sustainable health-promoting practices.6, 7

If positive changes are made, schools have the potential to greatly improve the life chances of children and adolescents. Beyond academic results that influence employment and income prospects, which are themselves strong determinants of future health, schools can equip students to develop general life skills and knowledge that will benefit their health in later life. However, if positive change is not achieved then not only will students miss out on health-maximising skills and knowledge, but also their physical and mental health can be damaged by experiences at school, which can be a powerful amplifier of inequalities. Examples of institutional failings include: bullying; lack of physical activity; and poor nutrition and poor support for students with long-term health conditions (including disabilities), those from refugee backgrounds, and those who identify as LGBTI. The intense national debates about the reopening of schools during the COVID-19 pandemic have laid bare the interconnectedness of health and education inequalities, which can worsen when schools close.8, 9 The COVID-19 pandemic is unlikely to be an isolated global health emergency; therefore, our societies and school systems must become more resilient for the future.

In this Viewpoint, we will highlight the value of health professionals thinking more strategically about their roles in school health, beyond their traditional roles of providing health services and delivering curriculum material about health-based subjects. Improving the health of all students requires a focus on reducing health inequalities, which requires structural changes that health professionals can help to bring about. We will also challenge health-services researchers to consider the clash of evidence-based practice and practice-based evidence that might occur when designing and evaluating school-based studies.

Key messages

  • Schools are an important influence on every student's health.

  • Beyond the implementation of ready-made programmes, the core contributions of schools to health improvement and reduction of inequalities are: having all children in school from a young age; keeping students in secondary education for as long as possible; and maximising students' educational success

  • Making every school a foundation for healthy lives is a matter of improving daily practices that promote health. The challenge, in the various educational contexts, is to engage education professionals and support them in developing management and teaching practices that positively affect the determinants of health of their students.

  • Health professionals can position themselves as catalysts for structural change, as they have many opportunities to advocate for, and participate in, the intersectoral implementation of reforms and innovations in school systems to promote the health of all students.

Section snippets

Schools and health: new challenges for an old relationship

All civilisations pass down prescriptive advice about health as part of collective wisdom, and since their foundation in the 19th century, contemporary school systems have been mandated to contribute to the improvement of population health. The knowledge that positive health behaviours can be acquired in childhood and adolescence has led political authorities to assign schools the task of improving health. From lessons about hygiene, tuberculosis, and alcoholism at the end of the 19th century,10

Health sector support for sustainable change in schools

Understanding the so-called modus operandi of school systems is useful background information that should help define the roles of health professionals and health-services researchers as future partners and agents of change within schools.30 There is a large evidence base regarding the implementation of education policies and the determinants that hinder or facilitate these processes.31, 32, 33 New approaches in complex education systems need to take into account the school culture, the overall

Experience of policy implementation in educational settings

The reviews of a large number of educational reforms or innovations, including those that were built on an evidence-based approach, are disappointing.42, 64 Once implemented and evaluated, education reforms do not always produce the expected effects (in terms of student achievement, scale, or sustainability).65 As early as 1995, within the educational research literature, Tyack and Cuban30 attributed the failures of educational reforms to insufficient consideration during the implementation

Producing and sharing knowledge

Studies produced in the context of controlled interventions are especially valuable in showing proof of principle, in comparing outcomes from different models, and in understanding cost-effectiveness. However, the necessary evidence to support the scaling up and sustainability of holistic approaches to health in schools is not limited to data produced in the experimental contexts that are well known to, and arguably most valued by, health professionals and health-services researchers.

Building bridges between education and health: the role of health professionals

Schools need a truly intersectoral partnership to maximise their potential in shaping children's and adolescents' health knowledge, attitudes, behaviours, and health outcomes. The levers to optimise the health of children and adolescents are shared by families, communities, policy makers, and professionals from health, social, and education sectors. The involvement of health professionals can be a powerful asset in gaining support for whole school endeavours. Since the population often views

Health professionals as catalysts for healthy changes in schools

Supporting every school to become a foundation for healthy lives means creating the conditions for schools to be inclusive (every child in school), equitable (ensuring the success of all children), and healthy (providing a learning environment that promotes health both now and in the future). The core business of schools is focused on increasing educational outcomes rather than the reduction of health problems, despite knowledge of how closely these objectives are intertwined.4 Schools should

Search strategy and selection criteria

We searched PubMed for relevant papers from Jan 1, 1980, to Aug 31, 2020, using the search term “health in schools”. Papers and books were also identified through searches of our own files and publications. Only publications in English and French were included. The final reference list was based on the relevance to the broad scope of this Viewpoint.

This online publication has been corrected. The corrected version first appeared at thelancet.com/child-adolescent on April 14, 2021

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      These approaches extend beyond treatment and management of health conditions, to address prevention and health promotion.9,10 While inter-sectoral collaboration is required to make every school a health-promoting school, inadequate coordination between health and education sectors has been frequently reported.8,11 In China, inter-sectoral collaboration around school health is largely concentrated around health services and the physical environment of schools.12,13

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