Objectives: Bullying and aggression among children and young people are key public mental health priorities. In this study, we evaluated the cost-effectiveness of a complex school-based intervention to address these outcomes within a large-cluster randomized trial (Inclusive). Methods: Forty state secondary schools were randomly allocated (1:1) to receive the intervention or continue with current practice as controls. Data were collected using paper questionnaires completed in classrooms including measures of their health-related quality of life using the Childhood Utility Index and police and National Health Service resource use. Further detailed data were collected on the cost of delivering the intervention. We calculated incremental cost-effectiveness ratios following the intention-to-treat principle using multilevel linear regression models that allowed for clustering of pupils at the school level. Results: Overall, we found that the intervention was highly cost-effective, with cost-per quality-adjusted life year thresholds of 13 pound 284 and 1875 pound at 2 years and 3 years, respectively. Analysis of uncertainty in the result at 2 years revealed a 65% chance of being cost-effective, but after 3 years there was a 90% chance that it was cost-effective. Conclusion: This study provides strong evidence collected prospectively from a randomized study that this school-based intervention is highly cost-effective. Educationand health-sector policy makers should consider investment in scaling up this intervention.

Education policy increasingly promotes action groups as a key strategy for student and/or staff participation in school improvement and whole-school health promotion. Such groups can coordinate multi-component interventions, increase participation and engagement, and enable local adaptations, but few process evaluations have assessed this. We evaluated fidelity, feasibility and acceptability of action groups as part of a trial of a whole-school intervention to reduce bullying and aggression and promote health in English secondary schools, which reported multiple health and educational impacts. Action groups involved students and staff, supported by external facilitators, and drew on data on student needs. They aimed to: coordinate implementation of restorative practices and a social and emotional competencies curriculum; review policies and rules; and enact local decisions to modify school environments. Our process evaluation used interviews, focus groups, observations and questionnaires to assess action groups’ fidelity, role in coordination, role in local adaptation, support from external facilitators and data on student needs, and acceptability in engaging members. Fidelity was high in the first two years but lower in the third year when external facilitators withdrew. Student needs data were perceived as useful, but views on external facilitators were mixed. Groups successfully reviewed policies and rules, planned activities and coordinated restorative practices, but were less successful in implementing the curriculum. Success was facilitated by the involvement of school leaders. Members reported high satisfaction and empowerment. Action groups are a promising strategy for leading whole-school health promotion. Implementation is supported by external facilitation, local data and involvement of senior managers.

BACKGROUND Teachers report higher levels of stress than most occupational groups. Burnout is a specific psychological condition that results from chronic job stress characterized by emotional exhaustion, low personal accomplishment, and depersonalization. This study considers associations between aspects of the school environment and teacher burnout. METHODS Exploratory analysis of baseline data from a cluster randomized controlled trial of 40 schools and 2278 teachers in the United Kingdom. Multilevel methods were used to consider the associations between different compositional and contextual aspects of the school environment and teacher burnout. RESULTS There was evidence for school effects on teacher burnout, evidenced by ICCs and likelihood ratio tests, supporting the association between school environment and teacher burnout. The factors most consistently associated with teacher burnout in our study were teachers' perceptions of the school's safety and support and student attitudes to learning. CONCLUSIONS The school environment does influence teacher burnout. More research is needed to develop and test causal pathways between the school environment and teacher burnout, and to understand ecological and individual predictors of teacher burnout and the interaction between the two.

Background: Bullying, aggression and violence among children and young people are some of the most consequential public mental health problems. Objectives: The INCLUSIVE (initiating change locally in bullying and aggression through the school environment) trial evaluated the Learning Together intervention, which involved students in efforts to modify their school environment using restorative approaches and to develop social and emotional skills. We hypothesised that in schools receiving Learning Together there would be lower rates of self-reported bullying and perpetration of aggression and improved student biopsychosocial health at follow-up than in control schools. Design: INCLUSIVE was a cluster randomised trial with integral economic and process evaluations. Setting: Forty secondary schools in south-east England took part. Schools were randomly assigned to implement the Learning Together intervention over 3 years or to continue standard practice (controls). Participants: A total of 6667 (93.6%) students participated at baseline and 5960 (83.3%) students participated at final follow-up. No schools withdrew from the study. Intervention: Schools were provided with (1) a social and emotional curriculum, (2) all-staff training in restorative approaches, (3) an external facilitator to help convene an action group to revise rules and policies and to oversee intervention delivery and (4) information on local needs to inform decisions. Main outcome measures: Self-reported experience of bullying victimisation (Gatehouse Bullying Scale) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale) measured at 36 months. Intention-to-treat analysis using longitudinal mixed-effects models. Results: Primary outcomes – Gatehouse Bullying Scale scores were significantly lower among intervention schools than among control schools at 36 months (adjusted mean difference –0.03, 95% confidence interval –0.06 to 0.00). There was no evidence of a difference in Edinburgh Study of Youth Transitions and Crime scores. Secondary outcomes – students in intervention schools had higher quality of life (adjusted mean difference 1.44, 95% confidence interval 0.07 to 2.17) and psychological well-being scores (adjusted mean difference 0.33, 95% confidence interval 0.00 to 0.66), lower psychological total difficulties (Strengths and Difficulties Questionnaire) score (adjusted mean difference –0.54, 95% confidence interval –0.83 to –0.25), and lower odds of having smoked (odds ratio 0.58, 95% confidence interval 0.43 to 0.80), drunk alcohol (odds ratio 0.72, 95% confidence interval 0.56 to 0.92), been offered or tried illicit drugs (odds ratio 0.51, 95% confidence interval 0.36 to 0.73) and been in contact with police in the previous 12 months (odds ratio 0.74, 95% confidence interval 0.56 to 0.97). The total numbers of reported serious adverse events were similar in each arm. There were no changes for staff outcomes. Process evaluation – fidelity was variable, with a reduction in year 3. Over half of the staff were aware that the school was taking steps to reduce bullying and aggression. Economic evaluation – mean (standard deviation) total education sector-related costs were £116 (£47) per pupil in the control arm compared with £163 (£69) in the intervention arm over the first two facilitated years, and £63 (£33) and £74 (£37) per pupil, respectively, in the final, unfacilitated, year. Overall, the intervention was associated with higher costs, but the mean gain in students’ health-related quality of life was slightly higher in the intervention arm. The incremental cost per quality-adjusted life year was £13,284 (95% confidence interval –£32,175 to £58,743) and £1875 (95% confidence interval –£12,945 to £16,695) at 2 and 3 years, respectively. Limitations: Our trial was carried out in urban and periurban settings in the counties around London. The large number of secondary outcomes investigated necessitated multiple statistical testing. Fidelity of implementation of Learning Together was variable. Conclusions: Learning Together is effective across a very broad range of key public health targets for adolescents. Future work: Further studies are required to assess refined versions of this intervention in other settings. Trial registration: Current Controlled Trials ISRCTN10751359. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 18. See the NIHR Journals Library website for further project information. Additional funding was provided by the Educational Endowment Foundation.

Education policy increasingly promotes action groups as a key strategy for student and/or staff participation in school improvement and whole‐school health promotion. Such groups can coordinate multi‐component interventions, increase participation and engagement, and enable local adaptations, but few process evaluations have assessed this. We evaluated fidelity, feasibility and acceptability of action groups as part of a trial of a whole‐school intervention to reduce bullying and aggression and promote health in English secondary schools, which reported multiple health and educational impacts. Action groups involved students and staff, supported by external facilitators, and drew on data on student needs. They aimed to: coordinate implementation of restorative practices and a social and emotional competencies curriculum; review policies and rules; and enact local decisions to modify school environments. Our process evaluation used interviews, focus groups, observations and questionnaires to assess action groups’ fidelity, role in coordination, role in local adaptation, support from external facilitators and data on student needs, and acceptability in engaging members. Fidelity was high in the first two years but lower in the third year when external facilitators withdrew. Student needs data were perceived as useful, but views on external facilitators were mixed. Groups successfully reviewed policies and rules, planned activities and coordinated restorative practices, but were less successful in implementing the curriculum. Success was facilitated by the involvement of school leaders. Members reported high satisfaction and empowerment. Action groups are a promising strategy for leading whole‐school health promotion. Implementation is supported by external facilitation, local data and involvement of senior managers.

Background Bullying, aggression, and violence among children and young people are some of the most consequential public mental health problems. We tested the Learning Together intervention, which involved students in efforts to modify their school environment using restorative practice and by developing social and emotional skills. Methods We did a cluster randomised trial, with economic and process evaluations, of the Learning Together intervention compared with standard practice (controls) over 3 years in secondary schools in south-east England. Learning Together consisted of staff training in restorative practice; convening and facilitating a school action group; and a student social and emotional skills curriculum. Primary outcomes were self-reported experience of bullying victimisation (Gatehouse Bullying Scale; GBS) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime (ESYTC) school misbehaviour subscale) measured at 36 months. We analysed data using intention-to-treat longitudinal mixed-effects models. This trial was registered with the ISRCTN registry (10751359). Findings We included 40 schools (20 in each group); no schools withdrew. 6667 (93.6%) of 7121 students participated at baseline and 5960 (83.3%) of 7154 at 36 months. Mean GBS bullying score at 36 months was 0.34 (SE 0.02) in the control group versus 0.29 (SE 0.02) in the intervention group, with a significant adjusted mean difference (-0.03, 95% CI -0.06 to -0.001; adjusted effect size -0.08). Mean ESYTC score at 36 months was 4.33 (SE 0.20) in the control group versus 4.04 (0.21) in the intervention group, with no evidence of a difference between groups (adjusted difference -0.13, 95% CI -0.43 to 0.18; adjusted effect size -0.03). Costs were an additional pound 58 per pupil in intervention schools than in control schools. Interpretation Learning 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. Copyright (c) 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.

Objectives: It has been suggested that students are healthier in schools where more students are committed to school. Previous research has examined this only using a proxy measure of value-added education (a measure of whether school-level attendance and attainment are higher than predicted by students’ social profile), finding associations with smoking tobacco, use of alcohol and illicit drugs, and violence. These findings do not provide direct insights into the associations between school-level aggregate student commitment and health behaviours, and may simply reflect the proxy measure being residually confounded by unmeasured student characteristics. We examined the previously used proxy measure of value-added education, as well as direct measures at the level of the school and the student of lack of student commitment to school to see whether these were associated with students’ self-reported smoking tobacco, alcohol use and school misbehaviour. Design: Cross-sectional survey. Setting: A total of 40 schools in south-east England. Methods: Multi-level analyses. Results: There were associations between school- and student-level measures of lack of commitment to school and tobacco smoking, alcohol use and school misbehaviour outcomes, but the proxy measure of school-level commitment, value-added education, was not associated with these outcomes. A sensitivity analysis focused only on violent aspects of school misbehaviour found a pattern of associations identical to that found for the measure of misbehaviour. Conclusion: Our study provides the first direct evidence in support of the Theory of Human Functioning and School Organisation.

Background: Government policy increasingly supports engaging communities to promote health. It is critical to consider whether such strategies are effective, for whom, and under what circumstances. However, 'community engagement' is defined in diverse ways and employed for different reasons. Considering the theory and context we developed a conceptual framework which informs understanding about what makes an effective (or ineffective) community engagement intervention. Methods: We conducted a systematic review of community engagement in public health interventions using: stakeholder involvement; searching, screening, appraisal and coding of research literature; and iterative thematic syntheses and meta-analysis. A conceptual framework of community engagement was refined, following interactions between the framework and each review stage. Results: From 335 included reports, three products emerged: (1) two strong theoretical 'meta-narratives': one, concerning the theory and practice of empowerment/engagement as an independent objective; and a more utilitarian perspective optimally configuring health services to achieve defined outcomes. These informed (2) models that were operationalized in subsequent meta-analysis. Both refined (3) the final conceptual framework. This identified multiple dimensions by which community engagement interventions may differ. Diverse combinations of intervention purpose, theory and implementation were noted, including: ways of defining communities and health needs; initial motivations for community engagement; types of participation; conditions and actions necessary for engagement; and potential issues influencing impact. Some dimensions consistently co-occurred, leading to three overarching models of effective engagement which either: utilised peer-led delivery; employed varying degrees of collaboration between communities and health services; or built on empowerment philosophies. Conclusions: Our conceptual framework and models are useful tools for considering appropriate and effective approaches to community engagement. These should be tested and adapted to facilitate intervention design and evaluation. Using this framework may disentangle the relative effectiveness of different models of community engagement, promoting effective, sustainable and appropriate initiatives.

The theory of human functioning and school organisation informed by Basil Bernstein's sociology of education suggests that to gain the commitment and promote the health of students, particularly those from disadvantaged backgrounds, schools require radical transformations eroding various boundaries': between and among staff and students; between students' academic learning and broader social development and welfare; and between schools and their local communities. Existing research examining this theory has reported associations between school-level proxy measures of student commitment and lower rates of student smoking, drinking alcohol, use of drugs and violence. But this research has not directly assessed whether reduced school boundaries explain this. We piloted a new scale derived from teacher reports to measure unhealthy school boundaries and examined its inter-item reliability and its criterion validity in terms of associations with various measures of school commitment and smoking. Data on boundaries came from 101 teachers across 40 schools. Data on student commitment and smoking came from 6667 students. We assessed reliability by examining correlations between scale-items and criterion validity in terms of associations with student-reported commitment and smoking. Inter-item reliability was sub-optimal but better within the subscales about boundaries between academic/broader learning and schools/local communities. The scale had good criterion validity, strongly associated with reduced student-reported school commitment and increased student-reported smoking. We reflect on the implications of these findings in terms of critical perspectives on health promotion in schools and the strengths and limitations of quantitative research in examining health behaviours as opposed to practices.

Objective: to explore the factors which influence the timing of the initiation of a package of publically-funded antenatal care for pregnant women living in a diverse urban settingDesign: a qualitative study involving thematic analysis of 21 individual interviews and six focus group discussions.Setting: Newham, a culturally diverse borough in East London, UKParticipants: individual interviews were conducted with 21 pregnant and postnatal women and focus group discussions were conducted with a total of 26 health service staff members(midwives and bilingual health advocates) and 32 women from four community groups (Bangladeshi, Somali, Lithuanian and Polish).Findings: initial care-seeking by pregnant women is influenced by the perception that the package of antenatal care offered by the National Health Service is for viable and continuing pregnancies, as well as little perceived urgency in initiating antenatal care. This is particularly true when set against competing responsibilities and commitments in women's lives and for pregnancies with no apparent complications or disconcerting symptoms. Barriers to access to this package of antenatal care include difficulties in navigating the health service and referral system, which are compounded for women unable to speak English, and service provider delays in the processing of referrals. Accessing antenatal care was sometimes equated with relinquishing control, particularly for young women and women for whom language barriers prohibit active engagement with care.Conclusions and implications for practice: if women are to be encouraged to seek antenatal care from maternity services early in pregnancy, the purpose and value to all women of doing so need to be made clear across the communities in which they live. As a woman may need time to accept her pregnancy and address other priorities in her life before seeking antenatal care, it is crucial that once she does decide to seek such care, access is quick and easy. Difficulties found in navigating the system of referral for antenatal care point to a need for improved access to primary care and a simple and efficient process of direct referral to antenatal care, alongside the delivery of antenatal care which is woman-centred and experienced as empowering. (C) 2016 The Authors. Published by Elsevier Ltd.

Substance use (smoking, drinking and illicit drug use) remains, a serious problem for young people living in industrialised countries. There is increasing interest in interventions to modify the school, environment, addressing the multiple upstream determinants of young, people's health. This article provides an overview of current theory, about how secondary school environments influence young people's, substance use before focusing on the Theory of Human Functioning and, School Organisation. It critically examines the extent to which this, theory is substantiated by quantitative and qualitative evidence and, considers how the theory might be elaborated to better inform future, empirical research.

For three decades there have been reports that the quality of schools affects student health. The literature is diverse and reviews have addressed different aspects of how the school environment may affect health. This paper is the first to synthesise this evidence using a review of reviews focusing on substance-use, violence and sexual-health. Twelve databases were searched. Eleven included reviews were quality-assessed and synthesised narratively. There is strong evidence that schools’ success in engaging students is associated with reduced substance use. There is little evidence that tobacco-control policies and school sexual-health clinics on their own are associated with better outcomes.

Purpose Health education in school classrooms can be effective in promoting sexual health and preventing violence and substance use but effects are patchy and often short term. Classroom education is also challenging because of schools' increasing focus on academic-performance metrics. Other school-based approaches are possible, such as healthy school policies, improving how schools respond to bullying, and parent outreach, which go beyond health education to address broader health determinants. Existing systematic reviews include such interventions but often alongside traditional health education. There is scope for a systematic review of reviews to assess and synthesize evidence across existing reviews to develop an overview of the potential of alternative school-based approaches. Methods We searched 12 databases to identify reviews published after 1980. Data were reviewed by two researchers. Quality was assessed using a modified Assessing the Methodological Quality of Systematic Reviews checklist and results were synthesized narratively. Results We screened 7,544 unique references and included 22 reviews. Our syntheses suggest that multicomponent school-based interventions, for example, including school policy changes, parent involvement, and work with local communities, are effective for promoting sexual health and preventing bullying and smoking. There is less evidence that such intervention can reduce alcohol and drug use. Economic incentives to keep girls in school can reduce teenage pregnancies. School clinics can promote smoking cessation. There is little evidence that, on their own, sexual-health clinics, antismoking policies, and various approaches targeting at-risk students are effective. Conclusions There is good evidence that various whole-school health interventions are effective in preventing teenage pregnancy, smoking, and bullying.

The integration of realist evaluation principles within randomised controlled trials (‘realist RCTs’) enables evaluations of complex interventions to answer questions about what works, for whom and under what circumstances. This allows evaluators to better develop and refine mid-level programme theories. However, this is only one phase in the process of developing and evaluating complex interventions. We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework. Intervention development, modelling, and feasibility and pilot studies need to theorise the contextual conditions necessary for intervention mechanisms to be activated. Where interventions are scaled up and translated into routine practice, realist principles also have much to offer in facilitating knowledge about longer-term sustainability, benefits and harms. Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups.

Meta-narrative review developed by Greenhalgh and colleagues is a new interpretive systematic review approach within an expanding portfolio of evidence synthesis methods that focus on context, meaning and process. Informed by Kuhn's notion of scientific paradigms, the method seeks to develop storylines of how research on a given topic unfolds over time, highlighting key discoveries and insights. This article reports how we drew on the meta-narrative approach in a review that examined the changing and contested nature of community' as understood across disciplines and research traditions. We discuss the challenges that arose in our review and the strengths and limitations of our approach. We conclude that the meta-narrative approach provides a useful framework for making sense of the multiple and changing conceptualisations of community while accounting for historical context. We recommend that an avenue for further development of the method is to consider Foucault's sociological approach to tracing knowledge.

The sexual health of young people in England is an urgent public health concern. While interventions to address young people's sexual health have focussed on knowledge, skills and contraception access, amazingly none in the UK has explicitly addressed the effects of the social hierarchies of gender and gendered behavioural ideals that shape young people's sexual expectations, attitudes and behaviour. The lack of attention to gender is a persistent gap in health research, practice and policy. A rigorous evaluation of such an intervention package would go some way to building an evidence base for challenging gender norms, which appear to be strongly associated with adverse sexual health outcomes.

BACKGROUND:Randomised controlled trials (RCTs) of social interventions are often criticised as failing to open the 'black box' whereby they only address questions about 'what works' without explaining the underlying processes of implementation and mechanisms of action, and how these vary by contextual characteristics of person and place. Realist RCTs are proposed as an approach to evaluation science that addresses these gaps while preserving the strengths of RCTs in providing evidence with strong internal validity in estimating effects.METHODS:In the context of growing interest in designing and conducting realist trials, there is an urgent need to offer a worked example to provide guidance on how such an approach might be practically taken forward. The aim of this paper is to outline a three-staged theoretical and methodological process of undertaking a realist RCT using the example of the evaluation of a whole-school restorative intervention aiming to reduce aggression and bullying in English secondary schools.DISCUSSION:First, informed by the findings of our initial pilot trial and sociological theory, we elaborate our theory of change and specific a priori hypotheses about how intervention mechanisms interact with context to produce outcomes. Second, we describe how we will use emerging findings from the integral process evaluation within the RCT to refine, and add to, these a priori hypotheses before the collection of quantitative, follow-up data. Third, we will test our hypotheses using a combination of process and outcome data via quantitative analyses of effect mediation (examining mechanisms) and moderation (examining contextual contingencies). The results are then used to refine and further develop the theory of change.CONCLUSION:The aim of the realist RCT approach is thus not merely to assess whether the intervention is effective or not, but to develop empirically informed mid-range theory through a three-stage process. There are important implications for those involved with reporting and reviewing RCTs, including the use of new, iterative protocols.TRIAL REGISTRATION:Current Controlled Trials ISRCTN10751359 (Registered 11 March 2014).

Background There has been increasing interest in involving the public in systematic reviews as they provide a shortcut to the evidence and arguably have greater influence over policy decisions and ultimately people's lives. Case examples of this involvement are rare, especially for reviews focused on children and young people. This study describes the process and impact of consulting with a young people's advisory group to inform decision making in a systematic review on the effects of schools and school environment interventions on children and young people's health.Methods Consultations were conducted with a pre-existing group of young people brought together to advise on public health research. Their views were sought at two key stages: (i) at the beginning when general views relating to the policy problem under study were elicited; and (ii) half-way through to advise on how to focus the review on key priorities.Results Young people's involvement in our review ensured that the scope of our review was appropriate and that issues which were important to young people were considered. The group was especially valuable in terms of prioritizing in a relevant and meaningful way. A crucial additional impact of involvement was young people providing 'early signals' of key themes for the synthesis.

This exploratory study adopts a socio-ecological approach to examine the context of school bullying. It asks: (1) what are students' accounts of bullying practices?; (2) how are these enabled and constrained by the school-environment?; (3) how is gender implicated? Qualitative data were collected from girls in two schools in London via focus groups (one in each school; students aged 12-15) and seven semi-structured interviews (in one school; students aged 16-18); and from school policy documents. Our interpretation of girls' accounts, informed by Giddens' structuration theory, suggests that bullying practices were spatially patterned in the schools and often characterised by the regulation of girls' sexuality and sexual-harassment. Repeated acts of aggression were fluid with regard to the bully and victim role, challenging the dominant view of bullying as characterised by consistent disparities in power between individuals. Schools structured bullying behaviour via policies and practices that ignored these forms of abuse and which focused on and may have been complicit in the making of stable 'bully' and 'victim' roles, thus indirectly contributing to the reproduction of unhealthy relationships between students. In terms of gender, traditional gendered and sexual discourses appear to structure the identities of the schools and girls in our study.