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The school environment and student health: a systematic review and meta-ethnography of qualitative research

Farah Jamal1*, Adam Fletcher2, Angela Harden13, Helene Wells4, James Thomas5 and Chris Bonell6

Author Affiliations

1 Institute for Health and Human Development, UH250, Stratford Campus, University of East London, Water Lane, London E15 4LZ, UK

2 DECIPHer UKCRC Public Health Research Centre of Excellence, School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff CF10 3BD, UK

3 Barts Health NHS Trust, London, UK

4 Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

5 Department of Childhood, Families and Health, Institute of Education, University of London, 20 Bedford Way, London WC1H 0AL, UK

6 Department of Social Policy and Intervention, Centre for Evidence Based Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK

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BMC Public Health 2013, 13:798  doi:10.1186/1471-2458-13-798

Published: 3 September 2013



There is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health?


Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach.


Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks.


Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.

Schools; Young people; Adolescent health; Health behaviours; Risk; Systematic review; Meta-ethnography; Qualitative