The sustainability of public health interventions in schools: a systematic review

Abstract

Background: The 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? Methods: Seven 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. Results: Of 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. Conclusions: Existing 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.

Evaluating The Implementation of The SWITCH® School Wellness Intervention Through Mixed Methods

“…School-based wellness programming provides an important opportunity to promote children's physical activity and nutrition behavior (1,2). However, factors within and outside the school environment have been found to hinder adoption, implementation, and sustainability of comprehensive interventions (3)(4)(5)(6). To advance research on school wellness programming, it is important to test approaches aimed at building capacity for more effective school wellness programming.…”

Evaluating the Implementation of the SWITCH® School Wellness Intervention Through Mixed Methods

“…The ndings add rich understanding to the steps needed to sustain school wellness programming in school settings (6,45), but it is important to acknowledge limitations. First, the SWITCH schools selfselected to enroll in the program, and were not representative of all schools in the state or country, limiting generalizability of these ndings.…”

“…Background School-based wellness programming provides an important opportunity to promote children's physical activity and nutrition behavior (1,2). However, factors within and outside the school environment have been found to hinder adoption, implementation, and sustainability of comprehensive interventions (3)(4)(5)(6).…”

“…Further, scant research has been conducted to understand stakeholders' perceptions of capacity and the ability to sustain evidence-based programming over time. Sustainability has been cited as a key issue in the D&I literature (6). To advance research on sustainability, the authors speci cally advocated for the use of 'methodologically stronger primary research, informed by theory', (p. 26) (6).…”

“…Sustainability has been cited as a key issue in the D&I literature (6). To advance research on sustainability, the authors speci cally advocated for the use of 'methodologically stronger primary research, informed by theory', (p. 26) (6). The use of mixed methods offers advantages for triangulating implementation data, and for identifying areas of dissonance between more objective indicators of implementation (18).…”