Farah Jamal, Adam Fletcher, Angela Harden, Helene Wells, James Thomas, Chris Bonell

1. Through what processes does the school environment influence young people’s health? Farah Jamal, Adam Fletcher, Angela Harden, Helene Wells, James Thomas, Chris Bonell Presentation by: Farah Jamal Research Fellow, Institute for Health & Human Development, UEL This project was funded by the National Institute for Health Research Public Health Research (NIHR PHR) Programme (project number 09/3002/08). Visit the PHR Programme website for more information. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the PHR Programme, NIHR, NHS or the Department of Health.

2. Background • Childhood and youth critical stages in the life-course • Evidence of ‘school effects’ on health from UK and international studies (e.g. West et al., 2004) • This suggests ‘school environment’ approaches needed as well as health education to promote health • School-environment approach: promotes health by modifying schools’ physical, social and/or cultural environment • However, quantitative studies of ‘school effects’ provide few insights regarding the pathways via which they occur

3. Research question and methods • Qualitative synthesis: Through what processes does the school environment influence young people’s health? • Qualitative studies reviewed as part of a larger mapping and evidence synthesis project to build a more comprehensive picture of school environment effects on young people’s health (Bonellet al., 2013) • Involved young people (DECIPHer’s ALPHA group), practitioners and other researchers • Two stages of screening to map evidence (stage 1) and review in-depth (stage 2), including the synthesis of qualitative studies through meta-ethnography (N=19)

4. Meta-ethnography approach • Meta-ethnography treats qualitative studies as ‘data’ and ‘relates, translates and synthesizes’ these (Noblit & Hare, 1988) • Increases the generalizability and analytic potential of qualitative research by re-interpreting meaning across multiple studies • Using this approach, we developed a 4 step method:(1) reading/re-reading included studies; (2) grouping studies by health topic and identifying key concepts within each topic; (3) ‘translating’ studies across health topics to identity meta-themes; and (4) theory development

5. Over-arching themes by health topic (step 2) Aggressive behaviours (N=10) (a) Performance, collective identity, and bonding, (b) Importance of ‘unowned’ space, (c) Poor staff-student relationships, (d) School rules and authoritarian control Going to the toilets in school(N=1) (a) Organisational and temporal arrangements, (b) School rules and authoritarian control limit personal freedom Substance use (N=4) (a) Performance, collective identity, and bonding, (b) Spaces in the school and health behaviours, (c) Poor staff-student relationships, (d) Drug use as a source of ‘escape’ Diet (N=2) (a) Organizational and temporal arrangements, (b) Importance of physical spaces and aesthetics, (c) The need to ‘escape’ from school at lunch times Sexual health (N=2) (a) Poor staff-student relationships, (b) Dis/ Empowerment The school environment and health: Meta-themes (step 3) Health-risk behaviours can be an important source of identity and bonding at school Health-risk behaviours concentrated in unsupervised ‘hotspots’ The importance of positive staff-student relationships for promoting health Unhappiness and stress at school can cause students to seek a means of ‘escape’

6. Characteristics of included studies • Largely informed by evidence from the USA and the UK • Studies focused mostly on aggressive behaviours and substance use • Majority of studies examined views and experiences of young people from: • disadvantaged communities and low SES families • Ethnic/ racial minority groups (particularly African-American students) • schools in urban settings • middle-high school / secondary school

7. Synthesis: Themes • Performance, collective identity and bonding • The social importance of space • Teacher student relationships, school policies and teacher practices • Ways of ‘escaping’ the school environment

8. Performance, collective identity & bonding Acting ‘tough’ • Young people (YP) often adopt ‘tough’ behaviours / ‘street’ styles at school, such as aggressive postures, smoking cannabis and tobacco • Such ‘performances’ can be an important source of peer bonding and security, especially in school contexts where YP feel educationally marginalized and/or unsafe Gender and ‘tough’ performances • In some cases young men showcase ‘toughness’ by playing young women in sub-ordinate and vulnerable positions.

9. The social importance of space ‘Unowned’ spaces in the school • Spaces that are unsupervised / ‘unowned’ become ‘hotspots’ for aggressive behaviour and substance use • These spaces are often ‘unowned’ as teachers focus only on classroom-based instruction and not the supervision of the wider school environment • … which has been ‘out-sourced’ to new technologies / new supervisory staff with little stake in the school • This is considered by YP to be an ineffective replacement of a caring teacher and appears only to displace problems Chaotic and unappealing spaces • Other spatial aspects of school canteens (e.g. crowded, aesthetics, etc.) can limit the potential for healthy eating at school

10. Teacher student relationships, school policies and teacher practices • Studies consistently conclude that positive teacher-student relationships are vital for a healthy school environment, particularly limiting ‘risky’ behaviours • Staff-student relationships may be constrained by: • School rules that are established and enforced by teachers without student input or consultation • Teachers are out of touch with the realities of young people’s lives • The lack of teachers supervision and support outside of the classroom instructional environment • Creates a vicious circle (especially for most vulnerable YP)

11. Ways of ‘escaping’ the school environment • Disengaged students often describe ‘escaping’ from their school at lunch-break to go to local shops and/or to smoke • Some students also report heavy alcohol and drug use as a means of ‘escaping’ anxieties and unhappiness about schools – either in responses to exam stress or a constant sense of failure and marginalisation

12. An extended theory and implications • Theory of human functioning and school organisation (Markham and Aveyard, 2003): We have extended this theory to outline how students not only react to school ‘instructional’ and ‘regulatory’ orders but also promote their own parallel, competing versions of these. • Key institutional features that may be amenable to intervention: marginalisation, lack of safety, lack of student voice, ‘unowned’ spaces, poor student-staff relationships, stress, etc. • The design of interventions should be co-produced with students so as to ensure they are appropriate and acceptable

13. Published research & qualitative studies diagram Full text not available n = 22 Excluded based on study design, focus or language (sift 1) n = 106 Duplicates n= 8 Evidence map of qualitative studiesn = 194 Included n = 58 Excluded based on conceptual richness/ relevance (sift 2) n = 37 Qualitative meta-ethnography published in BMC Public Health: http://www.biomedcentral.com/1471-2458/13/798 Full report published in Public Health Research: http://www.journalslibrary.nihr.ac.uk/phr/volume-1/issue-1 N = 21, (3 linked references) Unique studies included for in-depth review: n = 19

14. References • Bonell C, Jamal F, Harden A, Wells H, Parry W, Fletcher A, Petticrew M, Thomas J, Whitehead M, Campbell R, Murphy S, Moore L (2013) Systematic review of the effects of schools and school environment interventions on health: evidence mapping and synthesis. Public Health Research 1(1). • Noblit G, Hare R (1988) Meta-Ethnography: Synthesizing Qualitative Studies. London: Sage. • West P, Sweeting H, Leyland A (2004) School effects on pupils’ health behaviours: evidence in support of the health promoting school. Research Papers in Education 19: 261-291. • Markham WA, Aveyard P: A new theory of health promoting schools based on human functioning, school organisation and pedagogic practice. Social Science and Medicine 2003, 56:1209-1220.

15. Contact details Farah Jamal Institute for Health and Human Development University of East London UH250, Stratford Campus Water Lane London E15 4LZ Email: f.jamal@uel.ac.uk Twitter: FarahJamal7