Abstract
Objective:
Schools are important settings for health promotion. In schools, children and adolescents can be reached regardless of their social background, which represents a unique opportunity for promoting health. Several studies have demonstrated the importance of school leadership in initiating and sustaining health promotion; however, efforts to systematically review the influence of school leadership on school health promotion are still lacking. Hence, this paper analyses empirical studies published in scientific journals on school leadership and health promotion in schools.
Design:
Systematic literature review.
Method:
Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a review was conducted using two main databases: Web of Science and Scopus, which retrieved 51 eligible articles.
Results:
The review of these articles resulted in the identification of seven main themes – school leaders’ health; attitudes, knowledge and behaviour; accountability; support from school leaders; shared leadership approaches; capacity building and parent engagement.
Conclusion:
This systematic literature review expands the literature by highlighting the school leadership factors that promote school health promotion in Oceania, Europe, North America, South America, Africa and Asia continents. Future systematic literature reviews could explore studies and different aspects of health promotion by teachers, especially in the Asian context.
Introduction
Health promotion in schools has gained increasing attention among researchers wishing to develop a safe learning environment for students and school staff (Buijs, 2009; Dadaczynski et al., 2020a; Leahy and Simovska, 2017; Thøgersen et al., 2020; Viig et al., 2012). There has been growing interest in investigating enablers and barriers to the implementation and the success and sustainable practices of school health promotion. Despite the growing body of research, enquiry into school health promotion is still fragmented and sporadic (Dadaczynski and Hering, 2021).
The World Health Organisation (WHO) advocates a holistic approach to health promotion that goes beyond isolated, topic-specific and target-group-specific activities (WHO, 2017). A health-promoting school (HPS) engages with the physical and social environment, including interpersonal relationships, school management, political structures, and teaching and learning outcomes. Compared with standardised intervention programmes that are delivered with high implementation fidelity, this approach is characterised by context sensitivity, which requires adaptations to the specific circumstances and dynamic processes within an individual school (Darlington et al., 2018).
Many studies have found that facilities (Wu et al., 2019; Zervas et al., 2014), teachers’ and students’ physical and mental wellbeing (Castelli, 2019; Kim and Gurvitch, 2020) and nutrition education (e.g. healthy food) (Ooi et al., 2021) are essential to ensure a school is a healthy environment. Against this backdrop, school leaders are seen as central to the initiation and sustainability of standardised and complex school-health-promotion interventions (Dadaczynski et al., 2020a; Velarde et al., 2022). While many studies have focused on school health implementation strategies (Hills et al., 2015; Kremser, 2011), research on how school leadership supports health promotion in schools is still limited (Dadaczynski and Paulus, 2015).
In the research literature, school leadership has been widely recognised as having an influence on teachers’ attitudes and practices (Hallinger et al., 2014), school and school system performance (Adams and Velarde, 2018; Bush, 2021) and better student outcomes (Leithwood et al., 2019; Walker and Lee, 2018). While leadership in general is about influencing others to understand and work towards shared objectives (Yukl, 2008), health promotion leadership has been defined as ‘as leadership that is concerned with creating a culture for health promoting workplaces and values to inspire and motivate the employees to participate in such a development’ (Eriksson et al., 2017: 111).
Several studies have shown that school health promotion has the greatest effect when it is engendered by good-quality school leadership and strong staff support (Dadaczynski et al., 2020b, 2020c; Dimitropoulos et al., 2019; Samdal and Rowling, 2011; Warren et al., 2019). School principals hold the key to embedding health and wellbeing throughout the whole school and creating a healthy school (Bush, 2022; DeMatthews and Brown, 2019; Kostenius and Lundqvist, 2021; Skott, 2021). Nevertheless, efforts to systematically review the effects of school leadership on school health promotion are still lacking. This article attempts to fill this gap. The following research question guided the development of this systematic literature review: what school leadership factors influence health promotion in schools?
Methodology
A systematic literature review was conducted to address the research question. According to Moher et al. (2009: 264), a systematic literature review engages with ‘a clearly formulated question [and] uses systematic and explicit methods to identify, select, and critically appraise relevant research and to collect and analyse data from the studies that are included in the review’. Informed by such an approach, we synthesised the school leadership and health promotion in schools’ literature, in a systematic, precise and reliable way, to answer the research question. Our work was informed by preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, although the focus here was on conducting a literature review rather than a review of research studies.
Preferred Reporting Items for Systematic Reviews and Meta-analysis
The PRISMA guidelines aim to provide support to researchers when conducting systematic literature reviews (Moher et al., 2009). It requires a clear research question that permits a systematic and explicit method to collect and analyse data; inclusion and exclusion criteria and a defined timeframe over which to examine a large database of scientific literature (Sierra-Correa and Kintz, 2015). A systematic literature review process comprises three main stages. The initial stage involves defining a suitable search string and identifying relevant databases to compile the studies; the next stage involves screening the articles available in the databases based on identified inclusion and exclusion criteria and the final stage involves determining the eligibility of articles for analysis.
Identification
This review was conducted using two main databases: Web of Science and Scopus. Both are popular databases for systematic literature reviews (Adams and Muthiah, 2020) and cover more than 256 fields of study, including educational leadership and management studies. Web of Science (Social Science Citation Indexed) indexes 217 journals related to management, while Scopus indexes 1,398 journals related to education.
Initial searches included the terms related school leadership and health promotion in schools. For each database, these keywords were run separately, to ensure broader coverage of studies. Table 1 details the search string. In total, 3,494 documents were retrieved from Web of Science, and 123 were retrieved from Scopus at this first stage of the review. As one of our study selection criteria, we decided to include peer-reviewed journals only because these journals are considered a more reliable source of scientific data. Subsequently, overlapping and duplicate literature in both databases was excluded.
Search string.
Screening
During this stage, 3,617 documents were screened based on the inclusion criteria specified in Table 2 below.
Inclusion and exclusion criteria.
HP, health promoting.
Selection criteria
In the third and fourth stages, 51 eligible journal articles were identified as possible candidates for analysis. A thorough examination of each article’s title, abstract, research questions, problem statement, methodology and findings showed that they fulfilled the inclusion criteria and made them suitable for inclusion in this literature review.
Data abstraction and analysis
All 51 articles were assessed and analysed using an integrative review technique or a mixed-methods approach (Boland et al., 2017). Such an approach is suitable for the review and inclusion of both qualitative and quantitative evidence relevant to a particular research question (Sandelowski et al., 2007).
The selected articles were entered into a Microsoft Excel spreadsheet. Data extracted included the source type, author name(s), article title, journal title, topics, year, themes and research methods (i.e. qualitative, quantitative, mixed methods). Data were coded (Gough, 2007) where appropriate to facilitate subsequent quantitative analysis. For instance, each research method used in the studies was assigned a code (e.g. qualitative = 1, quantitative = 2, mixed methods = 3). The resulting spreadsheet therefore represented the ‘dataset’ analysed in this review.
In summary, the spreadsheet consisted of 51 rows (i.e. sources) and 8 columns (i.e. categories of information). Next, themes and subthemes were generated using a thematic analysis (Sandelowski et al., 2007). Figure 1 illustrates the steps taken during the systematic literature review analysis.
Process development of the systematic literature review
Results
General findings
The 51 eligible journal articles came from 18 countries (Figure 2); however, 18 journal articles were from Australia and Canada.
Total number of articles according to country.
Figure 3 shows the publication years for all 51 journal articles. While 2008–2010 only recorded one publication each, the number of publications increased rapidly between 2015 and 2021, with 82% (42 journal articles) of the total publications recorded in these years. In 2019 and 2020, the knowledge base on school leadership and health promotion recorded its highest numbers, with nine publications each year.
Total articles according to year of publication.
The authorship of the literature was highly dispersed, with a total of 170 different authors contributing to the 51 articles, including nine ‘key scholars’, who had each authored or co-authored at least four journal articles on school leadership and health promotion (Figure 4).
Number of publications by key authors in the literature.
An additional analysis revealed that the literature was widely dispersed across 27 different journals. These include general education journals (22%), health promotion and education journals (37%), health services journals (30%), and social science journals (11%) (Figure 5).
Literature by type of journal.
Findings from the thematic analysis
Analysis of the studies was analysed in relation to the types of health promotion undertaken in schools, and the methodologies applied in the studies identified six types of health programmes supported by school leaders in schools: general health promotion (e.g. tobacco prevention, smoking prevention, drug and alcohol prevention, knowledge and awareness on HIV/AIDS/STDs) (35 studies); physical health (e.g. physical activity) (4 studies); mental health (e.g. social and emotional learning; meditation) (8 studies) and nutrition education (e.g. healthy eating; healthy diet) (5 studies). Twenty-nine studies adopted a qualitative methodology, while 18 studies used a quantitative methodology, and 4 studies used mixed methods.
Focus of the studies
The analysis of the 51 journal articles focused on the influence of school leadership on school health promotion. Seven main themes were identified: a focus on school leaders’ health; attitudes, knowledge and behaviour of school leaders; accountability; support from school leaders; shared leadership approaches; capacity building and parent engagement.
School leaders’ health
School leaders’ health has not until recently been a focus for research on school health promotion. A quantitative study in Germany by Dadaczynski et al. (2020b) argued that the health of school leaders should be more widely studied, as studying school health promotion without understanding the health status of school leaders limits the depth and breadth of the findings. Elements of the findings in the study by Dadaczynski et al. (2020b) suggest that school leader’s self-efficacy is important to encouraging the development of health promotion in schools.
Attitudes, knowledge and behaviours of school leaders
Several studies have highlighted the significant role that school leaders’ attitudes, knowledge and understanding of health promotion play in the feasibility, effectiveness and impact of HPS on local communities (Aldinger et al., 2008; Clarke et al., 2017; Kwatubana et al., 2021; Roberts et al., 2016). Several studies have stressed the need for school leaders to be actively involved in health promotion issues and to consider the needs of various players in school organisation (Aldinger et al., 2008; Kwatubana et al., 2021). Aldinger et al. (2008) found that it took time for school administrators to develop a sound understanding of what HPS is about and how to implement it. Similarly, Roberts et al. (2016) found that school principals in Canada benefitted from ‘priming’ to develop their competencies and become familiar with HPS philosophy to prepare the school to move forward with implementation. A study in Taiwan found that school principals’ levels of understanding of HPS and willingness to sustain it were significantly associated with higher levels of HPS implementation and sustainability (Liu et al., 2019). To assist in institutionalising practices, it is important to explicitly demonstrate how health positively impacts learning and reduces student dropout and risky health behaviour at school and to use such findings as motivational factors (Clarke et al., 2017; Thøgersen et al., 2020).
While the abovementioned studies point to the importance of school leaders’ attitudes, beliefs and knowledge about health promotion, Dadaczynski et al. (2020c) showed that school leaders generally have limited health literacy, and they suggest integrating a focus on health literacy, HPS attitudes and competencies more strongly into qualifications and further training for school leaders. Bruce et al. (2012) found that HPS is often not implemented to its full extent, as school leaders lack the knowledge to do so. Leadership by qualified and experienced health promoters is necessary. In Australia, Ooi et al. (2021) reported that school principals prefer to focus on priorities and commitments other than health promotion. This proved to be a major barrier to implementing nutrition policies and practices. Graber et al. (2012) found that, although many school principals had limited knowledge, they were to meet legislative requirements where they existed and ensure their schools complied with the requirements of an HPS approach. A study by Wood and McDaniel (2020) in the USA found that principals need to develop their understanding of mental health in particular and prioritise it due to increasing demands from students and society more generally.
Accountability
School leaders are expected to play a key role in promoting the wellbeing of all members of the school. Roberts et al. (2016) found that school principals felt that their involvement was necessary for an HPS project to be successfully introduced and sustained within the school. Although principals felt uncomfortable acting as enforcers, they understood that this could be necessary in monitoring the HPS implementation process. Even if school leaders played a key role as caregivers to their staff, they felt that their staff could share this responsibility to a greater degree, particularly regarding the maintenance of personal-professional wellbeing (Anderson and Sice, 2016).
In countries such as Australia, some school leaders have managed to adopt an HPS approach and integrated health into the school’s mission (Gardner and Ollis, 2015). Doing so successfully requires a concern for health in the school management plan, including regular activities as part of the school calendar, and a yearly budget (Kitching and Van Rooyen, 2020). Also in Australia, McCalman et al. (2020) found a strong commitment among school leaders to seeing health as a major priority. Their study noted how some school leaders seek active partnerships and funding from health grants/providers in providing health care and wellbeing support to their students as part of quality improvement in this area. A study in Canada by Penney et al. (2018) suggested that the implementation of an HPS approach in each school is unique since it has to address local challenges, and careful leadership is required to serve students, parents and the community.
Support from school leaders
While the abovementioned studies emphasise school leaders’ accountability for health promotion, others accentuate the importance of school leaders’ support for health promotion initiatives, which has a strong influence over a school’s attempts to transition programme visions into actions and sustain a programme over time (e.g. McIsaac et al., 2015a; Viig et al., 2012; Wu et al., 2019). Several studies have reported on the importance of school principals assuming leadership in the early phase of the implementation process and establishing a committee or programme leader to coordinate and support ongoing work (Bonde et al., 2018; Zach et al., 2018).
Dimitropoulos et al. (2019) found that school leaders’ in New South Wales, Australia, supported training for staff for an in-school toothbrushing programme contributed to institutionalising and sustaining the programme. Regarding mental health, Glazzard and Rose (2019) reported that access to support was important to teachers in England, and many felt comfortable approaching their school leader or a member of their senior leadership team to talk about mental health problems. A longitudinal study by Hudson et al. (2020) in England found that schools with supportive, school leaders who were actively engaged in school development were more successful in implementing mental health programmes. In Australia, Hulme Chambers et al. (2017) identified school leadership as important in supporting the delivery of sexuality education and linking sexuality education policy to the work teachers undertook in school. More generally, school principals have an important role to play in strengthening teachers’ enthusiasm for an HPS programme (Zach et al., 2018) and overcoming potential indifference or resistance to it (McIsaac et al., 2017).
In contrast, Ekornes (2015) highlighted how weak support from the school leadership team often results in poor integration of mental health promotion into school routines and policy. Gugglberger et al. (2017) stated that school health coordinators in Austria experience a lack of support alongside pressure to perform and succeed from the school leadership team. In the same vein, Kwatubana (2018) found complaints about a lack of support from school managers in South Africa. School managers were often said to be busy and did not welcome programmes that clashed with their plans. Orendorff et al. (2020) found that, although school principals might agree on the benefits of a physical health programme for students, they expressed less agreement about their personal involvement in the programme, as some felt doing so was beyond their call of duty. In Poland, Woynarowska-Soldan (2015) found that school leaders had limited involvement in establishing and managing health-promotion initiatives among school staff. School coordinators felt that HPS policy could be more easily implemented when school leaders worked alongside teachers. All five studies in this theme reiterated how strong school leadership support was essential to meet students’ varying mental health needs.
Shared leadership approaches
Several studies have pointed out how collaborative approaches, particularly those working with teachers via a bottom-up rather than top-down process or the use of a combined top-down and bottom-up leadership approach, are important in facilitating school-based health promotion (Cassar et al., 2020; Kostenius and Lundqvist, 2021; Rainer et al., 2012). Other studies have highlighted how shared or distributed leadership is a way to improve the quality and comprehensiveness of health services for students (DeMatthews and Brown, 2019) and enable teachers to take ownership of school health (Roberts et al., 2016).
Kwatubana et al. (2021) found that school principals understood the responsibilities they needed to delegate to allow themselves time to plan, collaborate with others and monitor the performance of employees to ensure the effective implementation of health promotion in their schools. Findings from a study by McIsaac et al. (2015b) in Canada suggest that school leaders are critical to building a collaborative school culture to enhance HPS implementation at local level. Rainer et al. (2012) found that school leaders in the UK involved teachers in the development, planning and implementation of physical education (PE) programmes in the school. However, this responsibility was only devolved to other staff members because school leaders viewed PE as an additional burden in an already overcrowded curriculum. In Sweden, Skott (2021) reported that schools showed remarkable progress in health-promoting activities when principals supported work using a distributed leadership approach. In contrast, Viig et al. (2012) found that a top-down approach was regarded as effective in the development and implementation of school health promotion by programme leaders in Norway, as this way, teachers gave it greater priority, and school leaders had the authority to allocate time and resources.
Capacity building
Research has placed great importance on capacity building for sustainable health promotion in schools. Dadaczynski and Hering (2021) identified the need to support school leaders in Germany in their capacity building for health promotion through, for example, professional development and collaboration with local health services. In general, more evidence of the educational impact of health promotion is needed, particularly in secondary schools. Gugglberger and Dür (2011) found that Austrian schools have a clear understanding of HPS, but they need financial resources, knowledge of how to institutionalise health promotion and ensure sustainability and a way to establish partnerships and networks with other schools, health experts and parents.
In Australia, Lynch (2015) found that school principals strongly desired to have HPS specialists in their schools. Similar findings were found in later work by Lynch and Soukup (2017), who found that school leaders were concerned about HPS implementation since there were too few health education and PE teachers in schools. McIsaac et al. (2017) reiterated the importance of providing school leaders in Canada with adequate and appropriate staff capacity and support to integrate mental wellbeing into current health promotion work. Skott (2021) found that Swedish school principals were most successful when they managed to redefine their practice to ensure that leadership for health promotion was not an added responsibility. Rather, all school activities should be viewed through a health-promoting lens.
Parent engagement
Parental engagement in schools can promote a positive attitude towards education and health behaviours among students. Johnson et al. (2019) found that school leaders in Guatemala expressed in engaging parents to improve students’ health behaviour and to engage with increasing physical and mental health challenges. Lai-Yeung (2011) documented principals’ beliefs that school-family collaboration is important in enhancing the effectiveness of school food policies and developing healthy school environments in Hong Kong. Reynolds et al. (2019) found that Australian principals could work closely with parents to provide lunchbox guidelines for children in their schools. Notably, Yoshimura et al. (2009) observed that school principals in Laos were able to gather funds from parents to purchase first-aid equipment as part of the health and nutrition programme in their schools.
In contrast, Dix et al. (2019) observed that school leaders can face difficulties when attempting to engage and work effectively with parents. Keshavarz et al. (2010) shared that a lack of effective interactions with parents is one of the barriers to developing sustainable and effective HPS in Sydney, Australia. Ooi et al. (2021) reported a lack of parental support for implementing nutrition policies and practices as a major barrier in schools. In the UK, Clarke et al. (2017) found that school leaders felt that the responsibility to educate children about physical health lies mainly with parents.
The contradictoriness of these findings concerning parental engagement finding signifies a shortcoming of current HPS initiatives and calls for the development of resources to better meet the needs of school leaders regarding parent engagement. Torres and Simovska (2017) reported that school leaders in Ecuador often simply disseminated information and encouraged parents to comply with a school feeding programme. Parents were informed but had no real influence on decision-making in the school, discouraging them from becoming more engaged in the programme.
Discussion and conclusion
Studies of school health promotion can be found in several different fields of research, including education, social sciences and public health. By bringing together and integrating studies from different areas of enquiry, this systematic literature review integrates multiple perspectives on how school leadership can support health promotion in schools.
The review revealed several important findings. First, it was discovered that the literature on school leadership that supports health promotion in schools is largely contemporary, as 55% of the studies were published since 2017. These findings highlight the rapidly growing knowledge base in relation to the issue. The steep increase since 2017 may be linked to the growing awareness that school principals are key actors in health-promoting activities as part of their wider responsibility for education (DeMatthews and Brown, 2019; Kostenius and Lundqvist, 2021; Skott, 2021). Our review of the literature revealed that there is no generally accepted framework for leadership and health promotion in schools. Future research could lead to the development of such a holistic and comprehensive framework for leadership in schools, encompassing health promotion implementation, to ensure that educational leaders are equipped to lead successful schools that prioritise the wellbeing and holistic development of students, teachers and staff.
Second, most of the research on school leadership and health promotion in schools comes from Oceania (see Dimitropoulos et al., 2019), North America (see Wu et al., 2019), Europe (see Dadaczynski et al., 2020b; Ekornes, 2015; Viig et al., 2012) and, to some extent, the African continent (see Kwatubana, 2018). Research on school leadership and health promotion in schools is scarcer in Asia and South America (although the fact that our review focused only on published sources of English language may have created a misleading impression in this respect). Regardless, it is important to explore system differences within schools, as well as in different local and national contexts.
Third, to date, most research on school leadership and health promotion seems to have employed a qualitative methodology, with many studies using interviews and a few using focus group discussions to elicit the perceptions of informants. Only a small number of studies have used a quantitative or mixed-methods methodology. This finding calls for increased research utilising these latter approaches to clarify the relationships between factors that facilitate change (Viig et al., 2012) and to extend generalisability beyond individual schools to a wider context (Roberts et al., 2016).
Limitations
Like all other studies, this study has its limitations. First, our review involved data collection from only two databases: Web of Science and Scopus. A search using Google Scholar might result in more sources being identified, since this database is vastly superior when it comes to the social sciences and humanities. Furthermore, other important studies may be available in the grey and unpublished literatures.
Conclusion
Findings from this review reveal that strong leadership at the school level is essential for sustained and effective school-wide health promotion. School leaders were identified as gatekeepers to this, as their support has shown to relate to higher implementation of evidence-informed health programmes in schools.
Footnotes
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this research was funded by the Swiss Federal Institute of Technology Zurich (ETH) as part of the bilateral Science and Technology cooperation programme with Asia, project number COV_14_062020.
