Visita de Auditores externos para la presentación del Informe de Auditoría del 2013

After being presented with our preliminary findings on implementation, stakeholders acknowledged that receptiveness to and uptake of these types of integrated health and academic curricula hinged on several factors. The first is political will, in that there must be an external government mandate to support such programmes. The second, relatedly, is that there must be alignment of an integrated health and academic education programme within measured standards that reflect school performance. The third is internal political will, in that there must be support from management for the implementation of the programme as well as adequate budgetary allocation. Finally, there is a need for a programme curriculum that implementers (e.g. teachers) could be easily trained in, with ready-to-use materials. These factors are described in greater detail below.

Stakeholders agreed with our finding from the synthesis of process evaluations that it is not possible to identify a discrete subset of interventions that were most relevant to the UK. All interventions were potentially relevant to the UK with adaptation. The adaptations required would concern the detail of the intervention materials rather than the overall intervention approaches and theories of change.

External political will

Each of the four countries within the UK have different policies for health and wellness in schools. Unfortunately, we did not speak with stakeholders from Scotland or Northern Ireland, but the differences between England and Wales are stark. In England, PSHE is not a statutory subject. In Wales, Personal and Social Education is part of the basic curriculum for pupils aged 7–16 years at maintained schools.153

However, as of 2016 in the UK, Ofsted has introduced evaluation criteria linked to student health and welfare and personal development.40_{Integrated health and academic curricula may therefore help to}

address these wellness-based objectives as well as academic ones. As such, there may be varying levels of receptiveness to integrated health and academic curricula depending on the country context and the emphasis placed on health and wellness alongside academic attainment. The bottom line, according to stakeholders, was simply that there must be political prioritisation of the content within an integrated curriculum for it to have a chance at being taken up.

Alignment with evaluated learning objectives

As we already introduced, in the previous stakeholder consultation feedback on the findings from our synthesis of intervention theory, integrated health and academic curricula were generally viewed positively, but there was consensus that they would be far more likely to be taken up if they helped to meet academic learning objectives, such as the standards assessed by Ofsted. Strongly related to the previous consultation feedback, stakeholders consistently reiterated the need for political will and for this to be communicated to schools, for example via school metrics and inspection standards.

Young people on the ALPHA group could readily see the interconnections between reduced substance use and violence and improved academic attainment. Violence and other antisocial behaviour in schools could hamper learning. Student substance use could impede ability to learn. Adult policy stakeholders acknowledged that it was widely accepted that improved health among students leads to better academic outcomes, but that these relationships are difficult to evaluate.

Internal political will

There were comments from stakeholders on the necessity of buy-in, from both administrators,

implementers (usually teachers) and students. The first point raised was that schools must see available programmes as having the capacity to address an issue that the school already recognises as a problem. For example, substance use may not be perceived by all schools as an issue that needs to be addressed and, therefore, programmes emphasising substance use, regardless of whether or not they are integrated, may not be taken up.

It was reiterated on a number of occasions that there must be champions throughout the school who are willing to take up and support an integrated curriculum. A strong evidence-base for the effectiveness of these programmes to achieve outcomes was mentioned by most stakeholders as being a necessary and compelling factor that would influence uptake. Additionally, it was conveyed that students must also see the programme as being relevant, which was a point made by young people on the ALPHA group as well as by the adult policy stakeholders.

Beyond having enthusiasm for a programme, from a very practical point of view, adequate budget allocation by the school to integrated health and academic curricula was highlighted, as well as sufficient time to train teachers (see Effective teacher training). Young people made the point that programmes would not be well delivered when teachers lacked the time and resources to prepare themselves for this form of teaching. Additionally, having trained staff within the school who could mentor implementers and address any problems was seen as highly useful, but often lacking in many health programmes currently offered.

Effective teacher training

Teacher training was a point of interest. Many of the stakeholders had either led or been participants in continuing teacher training. There was a general agreement that it would be very challenging to get full days of teacher time to do training on integrated curricula. However, it was agreed that training in person, with lots of interactive activities and opportunities for role play, would generally be more effective than simply providing teachers with written materials. It was generally agreed that online training could be useful to supplement learning, but that it should not replace face-to-face training. The need to train the trainers was seen as being very important and also relates to having the necessary supports within schools. Furthermore, this type of model would allow a programme to be scaled up for delivery to a wider population. One important consideration regarding training for delivering integrated health and academic curricula in general is that programmes adopting this platform must be flexible to tailor materials to each school’s individual context. However, given the importance of an evidence base, it was also felt that programmes should have core components delivered with high fidelity to try to reproduce positive outcomes achieved elsewhere.

Differences between primary and secondary schools

In addition to the factors outlined earlier in this chapter, there were a number of reflections on the feasibility of integrated health and academic education in primary schools versus secondary schools. Although it was generally agreed that such interventions could be taken up by secondary schools, it was viewed as considerably less likely. In secondary schools, a narrower focus on academic attainment often consumes the seemingly constantly reducing space for health and wellness curricula. Teachers in secondary schools face enormous pressure for their students to perform well academically and may be less likely to risk academic attainment by giving space to health education, especially within core academic subjects. With fewer classes such as art and drama, which may provide a more natural platform for these integrated curricula, especially when practical skill development is emphasised, delivery in secondary schools may be further challenged. Other comments from both policy stakeholders and young people included the difficulty in discussing substance use and violence in secondary schools where students may already be engaged in these behaviours. Furthermore, it was felt that primary schools, which often use topic-based learning across several different academic lessons, may be much more appropriate platforms for integrated curricula than secondary schools.

Comparison with alternative personal, social and health education delivery models One stakeholder drew our attention to McWhirter et al.’s154_{Understanding Personal, Social, Health and}

Economic Education in Secondary Schools, in which different approaches to delivering PSHE are described, with an indication of the advantages and disadvantages of each approach. This source acknowledges teaching PSHE across the curriculum within other subjects as one potential approach. The authors highlight some key advantages, such as avoiding the need for discrete time slots for PSHE and increasing ownership

of the curriculum across the school. Among the disadvantages highlighted, there are some that resonate with our own findings. Related to‘internal political will’, McWhirter et al.154_{emphasise the need for}‘absolute’

commitment from the school leadership team. There are also several other key points raised that were not necessarily reflected in our findings, nor in our consultations with stakeholders. First, when health and academic objectives are brought together, there is a risk that the academic objectives may be seen as having lesser importance and, indeed, emphasis on health topics may become tokenistic. Second, if health education is integrated across a number of different subject lessons, then there is a risk that it will be difficult to ensure consistency and continuity. Third, the risk that evaluating learning objectives related to both health and academic education may prove challenging for teachers when monitoring student progress.154

Chapter 6 Synthesis of outcome evaluations

About this chapter

Parts of this chapter are reproduced or adapted from Melendez-Torres et al.155_{This is an Open Access}

article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Parts of this chapter are reproduced or adapted from Melendez-Torres et al.156_{This is an Open Access article}

distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

This chapter introduces the included outcome evaluations that met our inclusion criteria. It describes the quality of the evaluations, followed by our narrative and meta-analytic syntheses of these studies to address research question 4.

Included studies

We included 16 outcome evaluations of 14 interventions reported across 41 papers,3,51–53,60,83,87,88,90–93,95–98,100, 101,103,104,109–111,113–116,125,127–132,134,136–141_{of which 26 papers contributed evidence to our synthesis of outcome}

evaluations.3,51,52,60,83,87,90–92,95–98,101,104,109–111,114–116,125,127–129,132_{Included outcome evaluations and their}

characteristics and quality appraisals are included in Appendix 20.