title: The World Health Organization's Health Promoting Schools framework: a Cochrane systematic review and meta-analysis.
abstract: BACKGROUND
  Healthy children achieve better educational outcomes which, in turn, are associated with improved health later in life. The World Health Organization's Health Promoting Schools (HPS) framework is a holistic approach to promoting health and educational attainment in school. The effectiveness of this approach has not yet been rigorously reviewed.
  
  
  METHODS
  We searched 20 health, education and social science databases, and trials registries and relevant websites in 2011 and 2013. We included cluster randomised controlled trials. Participants were children and young people aged four to 18 years attending schools/colleges. HPS interventions had to include the following three elements: input into the curriculum; changes to the school's ethos or environment; and engagement with families and/or local communities. Two reviewers identified relevant trials, extracted data and assessed risk of bias. We grouped studies according to the health topic(s) targeted. Where data permitted, we performed random-effects meta-analyses.
  
  
  RESULTS
  We identified 67 eligible trials tackling a range of health issues. Few studies included any academic/attendance outcomes. We found positive average intervention effects for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small. On average across studies, we found little evidence of effectiveness for zBMI (BMI, standardized for age and gender), and no evidence for fat intake, alcohol use, drug use, mental health, violence and bullying others. It was not possible to meta-analyse data on other health outcomes due to lack of data. Methodological limitations were identified including reliance on self-reported data, lack of long-term follow-up, and high attrition rates.
  
  
  CONCLUSIONS
  This Cochrane review has found the WHO HPS framework is effective at improving some aspects of student health. The effects are small but potentially important at a population level.
authors.affiliation: School of Social & Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. beki.langford@bristol.ac.uk.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Langford
authors.affiliation: Social Science Research Unit, Institute of Education, University College London, 20 Bedford Way, London, WC1H 0AL, UK. c.bonell@ioe.ac.uk.
authors.forename: Christopher
authors.initials: C
authors.lastname: Bonell
authors.affiliation: School of Social & Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. hayley.jones@bristol.ac.uk.
authors.forename: Hayley
authors.initials: H
authors.lastname: Jones
authors.affiliation: School of Social & Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. dora.pouliou@gmail.com.
authors.forename: Theodora
authors.initials: T
authors.lastname: Pouliou
authors.affiliation: Cardiff School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK. murphys7@Cardiff.ac.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: Murphy
authors.affiliation: Jack Brockhoff Child Health & Wellbeing Program, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, 3053, Melbourne, Australia. ewaters@unimelb.edu.au.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Waters
authors.affiliation: Health Outcomes and Policy, Institute for Child Health Policy, University of Florida, 1329 SW 16th Street, Gainesville, FL, 32610-0177, USA. komro@ufl.edu.
authors.forename: Kelli
authors.initials: K
authors.lastname: Komro
authors.affiliation: Jack Brockhoff Child Health & Wellbeing Program, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, 3053, Melbourne, Australia. lgibbs@unimelb.edu.au.
authors.forename: Lisa
authors.initials: L
authors.lastname: Gibbs
authors.affiliation: School of Social & Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. drdanmagnus@gmail.com.
authors.forename: Daniel
authors.initials: D
authors.lastname: Magnus
authors.affiliation: School of Social & Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, BS8 2PS, UK. rona.campbell@bristol.ac.uk.
authors.forename: Rona
authors.initials: R
authors.lastname: Campbell
mesh_terms: D000124:Achievement; D000293:Adolescent; D015992:Body Mass Index; D002648:Child; D002675:Child, Preschool; D004032:Diet; D005260:Female; D005638:Fruit; D015438:Health Behavior; D006801:Humans; D008297:Male; D008603:Mental Health; D010809:Physical Fitness; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D012572:School Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data*; D014944:World Health Organization