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Author Manuscript
Health Place. Author manuscript; available in PMC 2023 August 03.
Published in final edited form as:
Health Place. 2023 July 01; 82: 103034. doi:10.1016/j.healthplace.2023.103034.
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Using systems thinking to understand how the South West -

School Health Research Network can improve adolescent health
and well-being: A qualitative process evaluation
Emily Widnall1,*, Patricia N Albers1, Lorna Hatch1, Georgina Hopkins1, Judi Kidger1, Frank
de Vocht1, Eileen Kaner2, Esther MF van Sluijs3, Hannah Fairbrother4, Russell Jago1,5,
Rona Campbell1
1Population Health Sciences, University of Bristol
2Faculty of Medical Sciences, Newcastle University
3MRC Epidemiology Unit, University of Cambridge
4Health Sciences School, University of Sheffield
5Centre for Exercise Nutrition & Health Sciences, School for Policy Studies, University of Bristol

Abstract
Schools offer a valuable setting to promote good health and mental well-being amongst young
people. Schools are complex systems and such systems interventions are needed to improve
pupil health and well-being. This paper presents a qualitative process evaluation of the South
West- School Health Research Network, a systems level intervention. The evaluation is based on
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interviews with school staff, local authorities and wider stakeholders. Given the complexity of
England’s educational system there is a need to intervene and monitor health at multiple levels and
to ensure close partnership working to effectively improve adolescent health through schools.

Keywords
school health research network; adolescents; health; mental health; well-being; systems-based
intervention; complex adaptive systems

Introduction
Adolescence is a key point in the lifecourse in which to promote health and well-being.
Risk taking behaviours increase during adolescence (Kipping et al., 2012), with adolescents
having increased control and agency over their own life (Daddis, 2011) and mental health
difficulties continue to rise over time with now one in six adolescents in the UK reporting
a probable mental disorder, an increase from one in nine in 2017 (Newlove-Delgado, 2021).

This work is licensed under a CC BY 4.0 International license.

*
Corresponding author: Emily Widnall, Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, BS8
2PL, emily.widnall@bristol.ac.uk.
Declaration of competing interests: We have no conflicts of interest to declare.
 Widnall et al. Page 2

Schools are a valuable setting for both health research and health improvement amongst
young people, with existing literature confirming the impact a school has on student health
(Bonell et al., 2013).

Secondary schools vary greatly in how far they prioritise student health and well-being.
A potential justification for not prioritising health and well-being in schools is that the
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more time spent on it, the less time there is for academic learning, resulting in lower
attainment; a ‘zero-sum game’ (Bonell et al., 2014). However, there is a strong evidence
base demonstrating that education and health are synergistic; healthy young people are better
learners (Bradley and Greene, 2013) and educational attainment is associated with living
a longer, healthier life. The role of schools is particularly important for adolescent health
given the increased sensitivity to peer influences and increases in risk-taking behaviours at
this age (Bonell et al., 2019). Additionally, school connectedness (the quality of students’
engagement with peers, teachers and learning in the school environment) has been suggested
as a novel target for the prevention of depression and anxiety in adolescents (Raniti et al.,
2022).

There have been a number of policies and strategies to improve health in schools. For
example, to encourage educational and health institutions to coordinate efforts to promote
health through schools, The World Health Organization established the Health Promotion
Schools Framework (HPS), which advocates a whole-school approach (WHO, 1997).
However, there are still many unknowns to the HPS Framework and its full potential remains
unevaluated (Langford et al., 2015, Langford et al., 2017). In 1998, England introduced The
National Healthy Schools Programme (NHSP) which aimed to encourage closer working
between health and education providers. Under this scheme schools could work toward an
award to achieve ‘Healthy School Status’ by performing well in personal, social and health
education, healthy eating, physical activity and emotional health and well-being (Barnard
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et al., 2009). However, this scheme came to an end in its National remit in 2011. Despite
this, a number of local authorities still use healthy schools initiatives across England which
encourage schools to work towards a range healthy school awards. A key challenge is that
the local authority initiatives are now all independent schemes and awards with no national
criteria or standardization.

Despite existing frameworks and initiatives (Hunt et al., 2015, Stirling and Emery, 2016),
several challenges remain regarding health improvement in school settings, even when
schools are supportive of it, difficulties comprise intervention delivery, sustainability and
cost-effectiveness and importantly, a lack of integration between academic, policy, practice
and public communities to facilitate co-production of school health improvement research
(Langford et al., 2017, Murphy et al., 2021).

Public health interventions are often complex and move beyond conventional thinking of
interventions as a ‘package’ of activities (Hawe et al., 2009). Preventive interventions in
schools ideally focus on the dynamic properties of the context they are set in and are
thought of in terms of how the school operates within a wider complex system. Systems
thinking conceptualises the interrelationships between components of a system (such as an
individual school and the broader education system it sits within) and their relationships

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with the system as a whole (Trochim et al., 2006). Systems approaches are being advocated
to address complex challenges in public health and can be of particular value in connecting
and synthesizing the distinct strands or structures in place, helping to identify strategies
for intervention sustainability, scalability, and reach (Huang et al., 2011). Schools can be
conceptualised as complex adaptive systems in their own right (Keshavarz et al., 2010), but
schools also sit within a broader educational and health system.
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The English secondary education system (ages 11-16 years) is particularly complex with a
wide range of school types including comprehensive (without reference to ability), grammar
(selective based on academic ability) and fee-paying schools. Additionally, some secondary
schools are managed via a local authority and others, including academies and free schools,
are run by academy trusts. Academy schools in England are publicly funded state schools
that run independently of local authorities and benefit from greater freedoms around the
delivery of the curriculum, length of terms, school days and staff conditions. The UK
government introduced the academies programme through the Learning and Skills Act
2000, in an attempt to improve pupil performance and address underperforming schools by
offering a private sponsor. A recent qualitative study highlighted the varied nature of health
promotion in academy schools (Jessiman et al., 2019), particularly given the absence of
national policy or guidance around health promotion in schools prior to the recent statutory
guidance on relationship, sex and health education (DfE, 2019). Variation in how schools
in England are managed feeds into variation in the time, resources and strategies devoted to
student health and well-being.

Despite an increase in the use of systems based approaches in public health research,
there remain limited examples of applying systems thinking to school health promotion
interventions. A recent systematic review of whole systems approaches to obesity and
other complex public health challenges found very few UK based studies (n=13) and
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a lack of school-based system approaches (Bagnall et al., 2019). Of the school-based

studies, the majority focused on primary schools. Further research is therefore required
to better understand the unique systems involved within the secondary education landscape.
Secondary school contexts and environments differ greatly from primary schools and health
challenges faced by students will also differ, particularly regarding risk-taking behaviour,
peer relationships and mental health.

This paper aims to use a systems perspective to evaluate the South West - School
Health Research Network (SW-SHRN) (Sharp et al., 2022) using National Institute of
Health Research, School for Public Health Research (NIHR SPHR) Guidance on systems
approaches (Egan et al., 2019). In line with the Medical Research Council’s 2021 framework
for developing and evaluating complex interventions (Skivington et al., 2021), this paper
aims to:

1. Better understand the wider system that school health research networks operate
in (educational, health and political)

1.1. Further inform and refine our working school systems map for England
(Figure 1)

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2. Understand how school health research networks could contribute to system

change

3. Understand how evidence generated from school health research networks can be
used to support decision making and policy planning.
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Method
Study design and participants
This process evaluation forms part of a larger pilot study of the SW-SHRN in which
secondary school students aged 12-15 (n=5,211) participated in a health and well-being
survey (Sharp et al., 2022). The survey topics include mental health and well-being, physical
activity and eating behaviour, sexual health, risky behaviours including smoking and alcohol
use, body image, sleep, peer support, cyberbullying, social media use and the school
connectedness (Sharp et al., 2022). Participating schools (n=18) and local authorities (n=7)
received tailored feedback reports on the student survey data and researchers worked closely
with schools to identify key areas of focus for health improvement and to facilitate sharing
of best practice between schools across the South West of England.

The process evaluation of this pilot study was divided into three components: 1) advice
and recommendations for working with schools to conduct health research; 2) barriers
and facilitators to implementing the SW-SHRN; and 3) using systems thinking to evaluate
SW-SHRN. This paper focuses on using systems thinking to understand how the SW-
SHRN operates within wider educational and health systems. Our write-up follows the
Consolidated criteria for reporting qualitative research (COREQ) reporting guidelines (Tong
et al., 2007).

Interview participants comprised school staff (n=11), local authority members (n=5), and
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wider key stakeholders (n=10), including policy makers, governors, academics, charity
leaders and school-based National Health Service (NHS) staff.

Data collection
Interviews took place between September 2021 and July 2022 within the context of the
Covid-19 pandemic, however there were no pandemic-related restrictions in place at the
time of the interviews. A question regarding the network and its potential impact to help
schools respond to the pandemic was included in the interview topic guide and the research
team anticipated that schools may have a heightened interest in student health and well-
being as a result of the pandemic.

All participating schools had a lead contact who were all invited to be interviewed
and participating and non-participating local authorities were invited to interview. Key
stakeholders were identified by the research team at the study outset, all key stakeholders
worked within children and young people’s health and well-being. 38 potential participants
were contacted via email by a member of the study team, of who 26 participated in an
interview. Of the 12 participants who declined, 9 did not respond to the initial email, 1
declined due to lack of capacity, 1 declined due to no longer working in young people’s

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health and 1 declined due a concern that by agreeing to interview their organisation might be
seen as endorsing the network.

Semi-structured interviews were conducted by EW, a female public health researcher with
experience in qualitative and mental health research in schools. Interviews ranged from 22
minutes to 67 minutes in length and took place remotely either via telephone or online
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platform (e.g. Microsoft Teams) with just the researcher and the interviewee present. Prior
to the interview, all participants received a full information sheet and consent form. The
information sheet contained an overview of the aims of SW-SHRN, a description of the
qualitative work and why they had been invited to be interviewed and information on
withdrawal, data confidentiality and what will happen to the results of the study. If written
consent was not received before the interview took place, verbal consent was taken (and
recorded) before the interview began. EW had no prior relationship with any interviewees
ahead of study commencement. School and local authority staff knew the interviewer
through their participation in SW-SHRN, stakeholders without any existing knowledge of
the study were sent a description of SW-SHRN and EW introduced herself and the purposes
of the study at the beginning of each interview.

Interviews followed two topic guides (see supplementary materials), the local authority/
stakeholder topic guide included questions on stakeholder views on the network, their
perceived barriers and facilitators, what outputs they would like to see from the network
and how to make the network sustainable and scalable. The school staff topic guide
included questions on school recruitment methods, experiences of participation, feedback on
administering the student survey, views on tailored school reports, how they would use the
data provided with their school and what would encourage them to continue being part of
the network. The topic guides were circulated among academic and public health colleagues
for feedback prior to use.
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Ethical approval for the study was granted by University of Bristol’s Faculty of Health
Sciences Research Ethics Committee (Ref. 110922).

Data analysis
A framework approach was used to analyse the interview data given its ability to incorporate
deductive analysis as well as allowing for inductive analysis (Gale et al., 2013). Codes were
both deductive (generated from the topic guide) and inductive (generated from interview
data). The following seven steps were observed:

1) Transcription: Audio recordings were transcribed verbatim, reviewed, and

checked for accuracy by EW prior to analysis. All transcripts were initially
read by EW to gain familiarity with the data.

2) Familiarisation: To continue familiarisation with the data, two researchers (EW

and LH) independently read six transcripts; two school contact interviews, two
local authority member interviews and two wider key stakeholder interviews.

3) Coding: EW and LH then independently annotated these 6 transcripts to

generate an initial list of codes and draft framework.

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4) Developing a working analytical framework: EW and LH then met to discuss

and compare these initial codes and agree on a final set of codes to apply to all
subsequent transcripts in order to create the analytical framework.

5) Applying the analytic framework: Although there were some distinct

differences between school contact interviews compared to wider stakeholders,
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there was sufficient overlap to allow all transcripts to be coded using the same
analytical framework. Subsequent transcripts were single coded by either EW or
LH, applying the agreed analytical framework, with further regular discussions
to clarify or expand the framework as needed.

6) Charting data into the framework matrix: EW and LH then charted the data
into the framework matrix by creating summaries and identifying key quotes for
each category (grouped codes).

7) Interpreting the data: EW and LH then met regularly to interpret the data,
mapping connections between categories, identifying central characteristics and
comparing data categories between and within cases to generate a set of themes
and subthemes. Themes and subthemes were then discussed, revised and agreed
by all co-authors.

NVivo qualitative data analysis software package (QSR International, version 12) was used
to aid data management.

Results
Table 1 provides a summary of interview participants by organisation type, role type and
gender.
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Theme 1: Fitting in with the wider landscape

A central theme throughout the interviews was the importance of SW-SHRN not being
a siloed system and the need for the network to become meaningfully embedded within
existing work on young people’s health and well-being across England. Stakeholders
acknowledged that there was a lot of activity around children and young people’s mental
health in schools and highlighted the importance of addressing gaps and aligning with
ongoing practice and avoiding reinventing the wheel. This theme was broken down into four
subthemes.

1.1 Complexity of England’s education system: a key challenge for systems-

based approaches—The first subtheme acknowledged the complexity of the school
system in England. This was primarily discussed in relation to recruiting schools to the
network and recognising the need to form close relationships with local authorities, multi-
academy trusts but also individual schools. Stakeholders discussed how local authorities
used to act as a central point of contact for schools, but that there was now substantial
variation between schools regarding their relationship with local authorities and no sub-
national strategic approach to health promotion in schools. For example some academy
schools have little to no contact with local authorities and have their own independent health
promotion strategies.

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“I think, getting into schools has become a lot more challenging just because of
how they’re set up and the academy structure. It used to be that you could go
through the local authority and have a quite straightforward way of getting into
schools because they were quite linked up with what they were doing. I think
now that...has broken down and… it’s very much up to the individual schools, or
certainly the academies, whether they want to engage or not.” (KS 6)
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“There’s variation across the region, in the strength of the relationship the local
authorities have with their local schools and academies. Previously, local authorities
have been the main stakeholder and gatekeeper for health promotion and a strategic
approach...to mental health and wellbeing. With that change towards a more
autonomous system for some of the schools, it’s not so easy.” (KS 4)

“Local authorities are really valuable, but there are areas where 90%+ schools are
academized. So if you’re just working with the local authority, it’s a tiny amount of
information that you’re getting. They do have some contact obviously with Multi-
Academy trusts, but the trusts are very independent and they can take or leave
advice. They are very much independent bodies and they’re all very different.” (KS
10)

Given the variation of health promotion efforts across schools in England, local authorities
discussed the benefits of a network offering a coordinated approach to reduce duplication of
similar work as well as the need for focussed efforts on school health improvement due to
reduction in resources within local authorities.

“We could save time and energy having a coordinated approach. So, then, yes, I
think networks of schools coming together to share good practice is useful. We’re
all essentially doing the same work, and local authorities have been quite depleted
in terms of staff, particularly school improvement advisors. So, we no longer have
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the resources to provide all the school improvement activities that we once did.
So, there’s certainly room in the marketplace for many providers, and I think it
would allow local authorities to perhaps focus more on different things that aren’t
provided elsewhere.” (LA 5)

1.2 Addressing changing needs and political interest—Key stakeholders,

particularly those working in Government departments, emphasised the importance of
school health research networks offering some targeted work to address unmet need with
a particular focus on addressing health inequalities. Politics and changing political interests
relating to health were also discussed with reference to the importance of demonstrating
meaningful change and the network being capable of demonstrating meaningful action. One
stakeholder highlighted the need for change to move beyond individual behaviour change to
address wider societal impacts on health.

“Currently, I’d say… the levelling up agenda [focus on improving lives in areas of
the UK which have historically received lower funds] … addressing inequalities…
you target your resources where it’s most needed whilst also having one eye
on what the general population needs. But you must have an explicit way to
demonstrate that this closes the gap… to address inequalities. You need to be

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able to demonstrate explicit links to outcomes that are deemed to be of interest,

politically… that changes over time…so having, a logic model behind it that
demonstrates those pathways.” (KS 3)

“It’s politics, you know? With health improvement it’s long term…we’ve got these
widening health inequalities, what do we know that will fix that, and what are we
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doing based on that? How do we address those entrenched problems and challenges
to our [young people’s] health, like obesity, smoking problems, physical activity
levels and readiness to learn, those kinds of things? That won’t be effectively
addressed by just focusing on individual behaviours and telling children and young
people what they should be doing.” (KS 4)

1.3 Linking with existing networks, services and intervention providers—

Stakeholders highlighted the importance of the network not being a siloed system. They
indicated a needs for the SW-SHRN to be embedded within the wider national picture of
school-based health and well-being and to take account of the existing work in this area if
it was it to be meaningful and valued over time. This included similar networks as well as
NHS services (Children and Adolescent Mental Health Service) and other local and national
approaches.
“It is thinking, “How do we make sure that any network in the South West is also
linked into other networks and is doing things that are complementary with other
networks?” You know, we are not the only people having this network.” (KS 7)

“How will they [schools] then link [network findings] in with the system, with
CAMHS (Children and Adolescent Mental Health Service) or whatever the local
system is or the national system? How will they then take that next step? So,
they’ve been told that a large number of people in Year 10 have got some kind of
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issue with anxiety, then what are they going to do next, that links into the wider
system? Because I guess what you’re looking for is system change.” (KS 1)

One stakeholder also discussed which areas are in need of support given the context of
existing priorities. For example, there is currently a large focus on areas of high deprivation,
but adolescents attending schools in more affluent areas are also reporting increased mental
health difficulties and this may be less of a focus, suggesting a potential change in which
areas could most benefit from a new network. This idea again reflected on SW-SHRN
operating within a wider landscape and not repeating existing efforts.

“It’s finding something that’s not already 1) that they’ve already bought in to, or
2) being offered...those schools that work with mental health support teams, part
of the mental health support teams’ role is to do assemblies, staff training sessions,
all of those kind of things, with a focus on mental health, but also more broadly
health and wellbeing and behaviour, because that all feeds in. So there are quite a
lot of schools with access to that kind of thing, but it’s inconsistent. And I think
a new offer would need to be targeted to particular areas or need…also at the
moment…it’s being prioritised in areas of high deprivation, or it’s all being done
on need indices. So there are big groups of schools that are in more affluent areas

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where mental health and wellbeing and health is still a really important problem,
but they are the areas that are not getting so much support at the moment.” (KS 10)

1.4 Regional vs. national network—Stakeholders discussed the strengths and

weaknesses of a regional versus national networks. Strengths of a regional model included
tailored provision, a richer local picture, and shared practice on a regional level, which was
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highlighted by one stakeholder as a current gap.

“I mean, at the moment, in terms of children’s health and wellbeing, clearly, we’ve
got the health behaviour in school aged children survey that runs every four years.
But that only generates data at a national level and not at a local or regional level.
And so the opportunity to act on that in, sort of, meaningful ways that connect with
local communities and schools is limited.” (KS 3)

However, many stakeholders also work on a national level, particularly with regards to
national policy and national children and young people databases. Stakeholders noted that,
in order to drive national policy, the network would need to evidence benefits beyond the
South West. Although, some stakeholders stated that we have existing networks generating
national data, and they can make it difficult to act locally and in a more targeted way.

“I think there is a question in there as well about how you grow the data to a
national data set.

People seem to come with this idea of schools measuring wellbeing for two goals.
And one is school improvement...but the other side is we need better data on
children’s health and wellbeing. And if we measure through schools, you can get
both of those things...if they’re all measuring consistently, you can flow up into a
huge national data set, as they have in Wales now. I think, at national level, there is
a potential for just richer data on health and wellbeing.” (KS 2)
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“So for me, the question is how does what’s happening in the Southwest
region around this agenda offer anything that has wider benefits beyond just the
Southwest?” (KS 3)

Theme 2: Partnership working

A key message from stakeholders was the importance of connecting individuals and
organisations involved in young people’s health and well-being. Our existing stakeholders
(government departments, charities, NHS initiatives, local authorities and academy
governors) provided a number of suggestions for partnership working between the network
and other individuals or organisations.

2.1 Representation in school—A number of suggested key partnerships for SW-

SHRN involved working closely with ‘on the ground’ health staff in schools, for example
SW-SHRN data could be shared and discussed with school nurses to create and implement
resources in the identified areas of need.

“One of my hobbyhorses [issues] when people are working in schools is to

remember school nurses. I know they are in some ways quite a scarce resource but

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they’re always there in the background. One of our desires…is to make the public
health role of school nurses much more evident than maybe it has been and the
desire if you look at the commissioning guidance around school nursing. So, my
advice would be to try and ensure that you link…with what the local school nurse
provider is doing…because sometimes they’re closer to the school structure and
what’s happening than the local authority is just because they’re in the schools.”
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(KS 6)

Teaming up with existing initiatives was also suggested, for example linking in with the
ongoing work of NHS school Mental Health Support Teams (MHSTs) and sharing the data
to inform more targeted support.

“Our model has an identified mental health lead in the school we work with,
our go-to person, if they’ve got access to [the networks] benchmarking data and
they can see their year sevens have got a really high number of children who are
showing high GAD7 [anxiety], then we think, “Right, we need to put something
into the year seven group.” There’s so much scope for working with [mental health
support teams] because you know this is a whole school approach.” (KS 9)

Stakeholders touched on the value of having a permanent/named person who understands

the local context and whose role is to respond to needs that are identified from the SW-
SHRN survey data.

“You need a constant learning team, to be reacting, to support our more statutory,
established education. So, a team of people who can create resources...that can
implement resources locally that are reactive to the local need, or what is happening
at that moment in time. They need to be permanently in post”. (LA 1)

2.2 Ofsted: opportunities and challenges—Some stakeholders suggested a

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potential future partnership with Ofsted (Office for Standards in Education, Children’s
Services and Skills) could be beneficial with Ofsted making use of the network data to
inform local area inspections. Ofsted is a government organisation in England that carries
out inspections to grade schools on their quality and performance. Schools are placed into
one of four categories; Grade one (outstanding), grade two (good), grade three (requires
improvement) and grade four (inadequate). After inspections, Ofsted publish their findings
so they can be used to improve standards in education.

“I think Ofsted should be a stakeholder...it’s just finding and navigating to the

people who manage the data, who use the data to inform area level inspections
and why they would be interested. They have been interested in the past, in our
national fingertips profiles to read and inform what they inspect at an area level,
local area inspections. So, I think making contact with and nurturing a relationship
and inviting them to contribute to be informed about this network, would be really
important.” (KS 3)

However, this idea was somewhat at variance with the perceived benefit of having a
university leading the network and the trustworthiness and impartiality which that implied.

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“Having an external organisation makes it more credible for the students, and
the schools, who might, I think, wrongly suspect that the council, I don’t know,
producing-holding data and might be using it in ways that they might not agree
with, or fiddling the data, to some extent.” (LA 5)

Ofsted also detailed that they would be unable to publicly endorse the network or any
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particular model and typically only report on what is working well in certain areas. This is to
avoid schools thinking they must take part in certain initiatives, which could take additional
time, money, or may be a burden on schools. Additionally, there was added concern with
government departments holding data due to power imbalances and potential misuse of data.
Therefore an Ofsted partnership would need careful consideration.

“The big one is the accountability risk. If government generates this school level-
identifiable data about every school...there is a risk that the data gets published
and people make league tables out of it, even if that’s not what it’s intended for.
So, there is that kind of risk, I think, of government having that data. Government
departments have a reputation and a power and there is a power imbalance there,
that feels like it wouldn’t be a good partnership with schools, collecting and
creating the data.” (KS 2)

2.3 Sharing data and practice across systems—Stakeholders offered advice on

how to work effectively with key partners and how ‘share data, good practice and key
learning from the network across the system. They stressed the importance of placing the
findings within the wider evidence base and using SW-SHRN as a platform to share existing
policy and practice as well as sharing network-specific findings.

“Just sharing what policies and things they have in place already. So, what is
working in different areas, so they could actually utilise [policies] in their own
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schools or an area that they’re not doing at the moment that might be helpful to
them. So, it’s just...sharing good practice, isn’t it. I think that’s really important,
and particularly if schools...would like to do more of that themselves, like peer
support. So, if someone’s got a particular issue in their school, they could look in
the network and see, “Well, actually, this area of health is really terrible in this
school. What can we do about it?” and they could ask other people in the network.”
(KS 5)

“If it is a living network, that it is really working collaboratively and sharing any
learning successfully across other systems.” (KS 1)
Stakeholders also discussed the usefulness of having shareable datasets to allow direct
access to anonymised data, particularly for analyses to inform policy.

“If there are big data sets that are produced, access to them. Not necessarily
identifiable data, you know, like in a usual data-sharing way, for our own research
and analysis. And the evidence that others could produce by analysing those,
so there is that evidence for national policy, I think would be the big thing.
Ultimately, I would like shareable data sets, obviously in a sensibly secure sharing
environment. So, research data sets.” (KS 2)

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Schools learning from one another and learning what works in particular health areas was
seen as key, particularly if schools could see a worked example or case study of the process
of using SW-SHRN data to make a change which then led to improved health outcomes.

“I think schools can always learn from other schools. I think when we know, in one
particular school... their students are a lot more mentally healthy, we need to look
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at those schools, and see what they’re doing, and see what we’re not doing. I think
that does help...knowing that you’re not getting

it, like, “The students aren’t 100% in this area, but in another school they are, so
what are they doing, and how can we compare? How can we use each other to
support our students?” I think is really important.” (SC 15)

“Obviously, every school is different, but if they can see it’s been beneficial in how
a school has grown or shifted their culture or something like that. So it doesn’t
feel like, “Oh, here are just some more people wanting to audit us and tell us what
to do.” But actually, “We went through this process and this is how things have
changed and there’s been an improvement,” is a really valuable thing to hear.” (KS
10)

Theme 3: Informing policy and allocation of resources

3.1 Informing policy and guidance—Key stakeholders noted the importance of large
datasets for informing local and national policy and guidance, but particularly noted the
strength of local/regional data to inform local priorities and to update both local authority
guidance and individual school policies.

“I think the risk from people in a strategic role, we’re kind of midstream. We’re
more upstream than at a local priority level. We’re working closer to the department
and to ministers, and it [network data] will provide us with a bit more of a
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solid picture to present, about how policy and interventions are likely to land in
local schools. Sat behind a desk in Whitehall, or wherever, churning out policy
documents or strategy is one thing, but it needs to be informed by who is going to
receive it, and who is going to work with it.” (KS 4)

“If we can see that there are issues that have caught up in the questionnaire, then
that will obviously galvanise us into thinking about how we can then influence
policies. We have certain documents anyway, which are guidance documents for
schools, and it may well be that they do get revised in the light of the findings…So
I think, actually, that there is quite a lot of potential for just changing the kind of
guidance, sample policies and things we give to schools, definitely.” (LA 2)

3.2 Distribution of funding and resources—Stakeholders, particularly local

authorities, detailed the usefulness of SW-SHRN data in terms of better distribution of
funding and allocating resources in known areas of need, which links with an earlier point
around targeting network activity based on existing practice and underserved communities.

“If we knew there were particular concerns in the South West around eating
disorders, then we could focus quite a lot of our work on that and we could seek

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funding in that area. So, it is really enormously helpful to have that information,
because then it can influence what we are going to do and the funding that we seek
and what we put our priorities on as well. And that would be the same for anyone,
for CCGs, for all areas.” (KS 1)

To address the aims of this process evaluation, Figure 3 maps out the themes and subthemes
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onto a working model of how SW-SHRN operates which illustrates a number of ways school
health research networks can contribute to system change and be used to support decision
making and policy planning. We are also hopeful that in the future we will be able to
conduct some further systems mapping work in light of these findings to refine and develop
our working systems map (Figure 1).

Discussion
The interviewees in this study highlighted the importance of the SW-SHRN linking to other
elements of the educational infrastructure to make sure that it did not become a siloed
system. Stakeholders consistently underscored the importance of ensuring that school health
research networks are meaningfully embedded within existing health and well-being policy
and practice in England. Stakeholders also stressed the need to maintain and strengthen
multi-sectoral partnership working as this is needed to facilitate continuous knowledge
sharing between key partners, and drive national policy and planning.

Key themes identified in this study are consistent with evidence from other system-based
health evaluations finding that strong relationships between stakeholders, allowing time to
build relationships, trust and local/community capacity, embedding initiatives in a broader
policy context and ensuring the approach is robust and sustainable are all key to building a
successful whole systems approach (Garside et al., 2010, Bagnall et al., 2019).
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The value of sharing ‘what works’ among schools was another important finding, with
recommendations to share success stories, present health area-specific case studies and
highlight best practice to participating schools within the network. As well as sharing what
works among schools, school staff, local authorities and wider stakeholders all requested
that the networks findings were embedded into existing policy and evidence to make them
more meaningful for both policy and intervention planning. Rather than giving schools a
static report of findings, researchers could play a role in interpreting the findings in line
with existing policy and evidence to provide policy briefings and evidence summaries in lay
terms for schools and local authorities. This illustrates the multiple functions of SW-SHRN,
working at different levels across the system, e.g. highlighting areas of focus for individual
schools, indicating areas to target provision for local authorities and providing up to date
evidence of adolescent mental health for wider policy planning. Providing up to date data
as it becomes available in the form of ‘feedback loops’ has been shown to be effective in
previous whole school approaches allowing data to continuously inform activity and allow
for responsive and continuous improvement (Kearney et al., 2016).

An important finding in relation to future school inspection frameworks and an increasing

focus on health and well-being data within schools, was schools’ concerns around
being judged or ranked on their health data and the existing power imbalances between

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government bodies and schools. Many stakeholders believed it would be important to assess
schools on their engagement in promoting health and well-being in schools, rather than any
comparison between health and well-being outcomes. Ofsted is likely to play a key role in
health and well-being promotion in schools in the future and could be an important area of
future growth of the network, however this relationship needs to be more closely evaluated.
Although the Welsh SHRN model work closely with Ofsted (Estyn in Wales) we are yet to
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see evidence to support the pros and cons of this partnership.

Understanding different stakeholder perspectives regarding the delivery of SW-SHRN and

the use of SW-SHRN data, enabled us to identify strategies for intervention sustainability
and scalability. Strategies for success centred around partnership working at multiple levels
and embedding network activity within national and local policy. Stakeholders noted the
strengths of offering both tailored local resource targeting whilst providing data to inform
national policy and planning. Network findings allow data-informed planning for schools,
local authorities and policy makers.

Future research should aim to gather deeper insights into more components of the health and
education system in England to more formally map out the system in which SW-SHRN sits
and examine where and how school health research networks can fit into this system.

Strengths and limitations

This study provides unique insight into applying systems thinking to evaluating school
health research networks, a novel evaluation that is yet to be carried out on other
existing networks. This study also benefits from seeking perspectives from a wide range
of stakeholders, multiple local authority areas and a variety of school staff from eleven
individual schools. However, the following limitations must also be acknowledged. There
are several types of school that did not participate in the SW-SHRN pilot including free
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schools, faith schools and independent schools, therefore school staff perspectives from
these different school types may differ to our reported findings. Equally, members from only
5 of a total of 15 local authorities in South West England were interviewed as part of this
process evaluation and therefore local authority viewpoints are not necessarily representative
of the whole of the South West region. It will be important to run further qualitative work if
additional school types and local authorities are recruited to the network in future. Further
recruitment and expansion of SW-SHRN is therefore required to gain a more in-depth
understanding of the regional system and gain perspectives of the other local authorities in
terms of how their structures operate. Additionally, there is potential for such networks to
improve the health and well-being of staff as well as students, however the SW-SHRN pilot
study did not collect staff health and well-being data, which could be another important area
for future expansion.

Conclusion
This qualitative process evaluation details the barriers and facilitators to implementing a
regional school health research network to improve adolescent health and well-being. The
findings highlight the vital nature of multi-sector partnership working and intervening and
monitoring at multiple levels.. The findings also draw attention to the complexity of the

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 Widnall et al. Page 15

current landscape of school health promotion in England and the need to take a systems
approach. School health research networks can play a key role in facilitating the needs
within the system. These include collaboration, identifying local need, better targeting of
resources, sharing data and best practice across different parts of the system and informing
regional and national policy.
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Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgements
We would like to thank all participating schools and school staff, local authorities and wider stakeholders who
participated in an interview.

Funding
This study is funded by the National Institute for Health and Care Research (NIHR) School for Public Health
Research (SPHR), Grant Reference Number PD-SPH-2015. The views expressed are those of the author(s) and not
necessarily those of the NIHR or the Department of Health and Social Care.

Data availability
The datasets used and analysed during the current study are available from the University of
Bristol data archive, https://data.bris.ac.uk/data/.

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Figure 1. A working school systems map for England

Figure 1 shows our working systems map, which depicts how the SW-SHRN operates
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within the English education system. With the network as the central point of the map, we
have bidirectional relationships (depicted by the black arrows) with schools, Multi-Academy
Trusts (MATs), Local Authorities (LAs), and various government departments. In future, the
network hopes to establish bidirectional relationships (shown with orange, dotted arrows)
with third sector organisations (such as mental health charities), families and carers of the
school students, and other governmental departments, for instance the Office for Health
Improvement and Disparities (OHID) or the National Pupil Database. This figure also shows
the bidirectional relationships between the various actors in this map, for example, LAs with
Schools, MATs, and third sector organisations.

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Figure 2. Diagram of Qualitative Themes and Subthemes.

Three main themes were developed from the framework analysis; 1) Fitting in with the
wider landscape; 2) Partnership working; 3) Informing policy and allocation of resources.
The key themes and subthemes are summarised in Figure 2.

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Figure 3. A working model of SW-SHRN based on the main themes and subthemes
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Table 1
Summary of Key Stakeholder Interviews by Organisation, Role Type, and Gender
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Interview Organisation Type Role Type Gender

KS1 Charity Mental health lead Female

KS2 Government department Mental health, national Female

KS3 Government department Public health, national Female

KS4 Government department Public health, regional Male

KS5 Government department Research lead, national Female

KS6 Government department Public health, national Female

KS7 University Clinical Psychologist/Academic Female

KS8 Academy Trust Governor Male

KS9 NHS Mental Health Support Team Female

KS10 Government department Mental health, regional Female

LA1 Local authority Advanced Public Health Practitioner, Health & Well-being Female

LA2 Local authority Health Improvement Specialist: Children & Young People Male

LA3 Local authority Children & Families Commissioning Male

LA4 Local authority Lead for Health and Well-being Female

LA5 Local authority Children and Families Male

SC1 Participating school Deputy Head Teacher Female

SC2 Participating school Pastoral Support Worker Female

SC3 Participating school Deputy Head Teacher Female

SC4 Participating school Head of Personal Development Curriculum Female

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SC5 Participating school Deputy Head Teacher, Student Welfare & Behaviour Female

SC6 Participating school Music Teacher, Lead for Looked After Children Male

SC7 Participating school Mental Health & Well-being Coordinator Male

SC8 Participating school PSHE Lead Female

SC9 Participating school Assistant Headteacher Female

SC10 Participating school Deputy of Physical Education and Health, Personal, Social Health & Economic education Female
Lead

SC11 Participating school Deputy Head Teacher Female

‘KS’ = key stakeholder, ‘LA’ = Local Authority ‘SC’ = School Contact

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