Examples of interventions designed in a manner consistent with a view of schools as CAS

According to CAS thinking, there is a need to understand system functioning and use approaches to intervention development which recognise variation in system starting points. This may facilitate the development of contextually tailored interventions which maintain fidelity in terms of function rather than form (Hawe et al., 2009b; Patton et al., 2003). Data-led needs assessment provides a potential method of doing this and achieving consistency with a complex systems perspective. There are some promising examples within the literature of efforts to support schools in the use of

60 data-led needs assessment on health-related issues to adapt interventions to different contexts in this manner. Such efforts work to shape school health improvement, and subsequently, student health through employing a set of standardised processes rather than standardised intervention form.

In Canada the School Health Action Planning and Evaluation System (SHAPES) pioneered school feedback systems which provide tailored feedback on student health (Cameron et al., 2007; Leatherdale, Manske, Wong & Cameron, 2008). Moreover, the Alberta Project Promoting active Living and healthy Eating in schools, provided feedback reports on diet and physical activity to schools with provincial data for comparison, with trained School Health Facilitators supporting dissemination, translation and application of data within a HPS framework; positive impacts on diet, physical activity and obesity have been observed (Schwartz,

Karunamuni & Veugelers, 2010; Storey, Spitters, Cunningham, Schwartz & Veugelers, 2011). This was however a highly resource intensive model, involving the installation of a new full-time health facilitator into every school. Hence, it is perhaps unlikely to be a scalable model, particularly in a political climate in which resources are scarce. Therefore, key questions remain surrounding how best to support schools in using data for needs assessment and action planning, supporting existing staff (i.e. Wellbeing Leads) in more efficiently and effectively achieving change in school systems. Implementation of action research groups has been employed elsewhere to achieve school system-level change for pre-specified health issues (Bond, Glover, Godfrey, Butler & Patton, 2001; Bonell et al., 2015). School action groups as well as the use of local survey data could help to create positive feedback loops and achieve system level change within different contexts.

Two examples of interventions which explicitly incorporate a recognition of variability in system starting points as part of a whole school approach are the Gatehouse Project, which focused on improving health risk behaviour (Bond et al., 2001; Bond et al., 2004) and the Inclusive Study, which focused on reducing bullying and aggression (Bonell et al., 2015; Fletcher et al., 2015). These

interventions were designed as a set of processes, which aimed to understand the needs of a specific system in order to adapt the intervention to take contextually

61 appropriate action within each school, whilst remaining true to intervention logic (Hawe et al., 2004a; Patton et al., 2003).

The Gatehouse intervention was a whole school intervention to improve social and learning environments in Australian schools and was implemented through

conducting a survey of the school climate to measure student perceptions of security, communication and participation within the school. This allowed for an assessment of the pre-intervention context, which was used to provide individualised school- level feedback. A school-based action team was also created (Patton et al., 2003). These action teams were unique to each school and comprised of a team adapted from existing relations within the school, including staff involved in senior administration, curriculum, student welfare, heads of year, students and external agencies and were often embedded within the schools’ formal organisational structures. Action teams also consulted with researchers from the project who acted as external ‘critical friends’ to facilitate implementation.

Implementation processes varied across schools due to differing levels of readiness to change and availability of resources. The provision of health reports assisted with the utilisation of existing and new health promotion programmes to respond to the needs of each school in an individualised manner, leading to a decrease in risk of 3- 5% between intervention and control groups for drinking, smoking and friends’ alcohol and tobacco use. No significant effects were observed for social

relationships, school connectedness or depressive symptoms (Bond et al., 2004). Although the Gatehouse Project was forward thinking for its time in moving towards a settings approach and away from individualised behaviour-led interventions, it was not explicitly designed or evaluated using a complex systems framework. Since then, CAS thinking has advanced and the programme has been considered and critiqued from a complex systems perspective (Hawe et al., 2009a). For example, the fact that schools were given freedom, within certain boundaries, to adapt the intervention to local context is compliant with a complex systems perspective, as is the strong emphasis on understanding context prior to developing contextually appropriate interventions. Moreover, the authors described how they extended this methodology within a Gatehouse replication study, named Creating Opportunity for Resilience

62 and Engagement (CORE), by employing longitudinal social network analysis with teachers to study the dynamics of change processes (Hawe et al., 2009a).

The Inclusive study provides a further example of an intervention based on standardised process, whereby pre-intervention context data was collected and utilised for tailoring to context. Pre-intervention context data consisted of a survey of the prevalence and determinants of bullying and aggression. The logic model

specified that an action group decided priorities and school rules and policies and peer mediation were reviewed and revised in light of the pre-intervention contextual data (Bonell et al., 2014). In addition to this, school staff received training and a new Year 8 social and emotional skills curriculum was implemented. This resulted in both students and staff reporting that priorities for reducing bullying and aggression in schools were identified using the school survey data and subsequently acted upon. The data served to either validate and reinforce staff and students’ preconceived ideas regarding the priorities that needed to be addressed, or to help them to discover new priorities which they were not aware of previously (Fletcher et al., 2015). However, this pilot study excluded the most deprived schools who were rated as ‘unsatisfactory’ by the independent schools’ inspectorate. These schools may have a high rate of aggression and bullying and thus, it remains to be seen whether this type of partnership working and involvement of young people could have a positive effect in more deprived schools (Fletcher et al., 2015).

Both the Gatehouse and Inclusive interventions incorporated school action groups, of which staff students, parents and families were members. This is a way of

connecting and supporting information flow between many of the sub-systems within the school and other systems external to the school, such as year groups and classes. However, there is only so much that can be actioned as a result of these action groups, as complex school systems are dependent yet autonomous. Therefore, they may only action suggestions from the group within a set of fixed possibilities and within the rules of the school (Keshavarz et al., 2010). For example, the level of support for change from senior management may act as either a barrier or facilitator. Despite this, the Gatehouse Project found that an advisor collaborated with and guided school health improvement teams effectively through needs assessment,

63 planning, implementation, evaluation and reassessing priorities (Bond et al., 2001). The Inclusive study also found that structural changes were more likely in one school where a new Head Teacher had just been appointed, thus highlighting that a higher level of willingness to change may be seen in schools with relatively new management teams (Fletcher et al., 2015).

The above represent examples from the literature of understanding system context prior to intervening and utilising the knowledge obtained to strategically target aspects of the complex school system. Hawe (2015) goes as far as to state that researchers have a moral obligation to ensure that any intervention designed is likely to fit with its system and hence have a likelihood of effectiveness. These findings demonstrate the need to take into account the different starting points of each system, before intervening and to design interventions which may be adapted according to the needs of each school. However, while such feedback loops may work to increase schools’ awareness of their strengths and weaknesses in terms of health, these may only induce change if schools value these outcomes. This highlights a need for dual action, whereby feedback is coupled with persuading schools to value health outcomes and, thus, altering rules and ethos. Rules and ethos were targeted by the interventions outlined above. For example, the Gatehouse project attempted to enhance students’ feelings of security, self-regard and positive communication (Bond et al., 2001), whilst the Inclusive project targeted bullying and aggression (Bonell et al., 2015). Moreover, the Inclusive study found that the

intervention was prioritised within schools as the emphasis on increasing student voice and participation could be used to impress the national school inspectorate (Bonell et al., 2015; Fletcher et al., 2015).

Further to this, the non-linearity and unpredictability of complex systems is demonstrated by the various unpredictable outcomes within the Inclusive schools (Fletcher et al., 2015). For example, one school did not include a senior member of staff within their action group and had relatively few actions delivered compared to the other schools. In contrast, a Head Teacher from a different school commissioned new surveys and accessed additional data sources. The outcomes of both projects, such as a decrease in the reporting of regular smoking among students in the

64 Gatehouse project, demonstrate change and emergent outcomes. This is likely to be caused by a combination of all parts of interventions and the way in which they interact with the characteristics of the complex systems in which they are implemented (Keshavarz et al., 2010).

Despite this consistency with CAS thinking, measurements of pre-intervention context were limited and consisted solely of surveys to measure student perceptions of the school climate and the prevalence and determinants of health-related

behaviour (Bonell et al., 2015; Patton et al., 2003). Whilst this facilitates the identification of priority areas, employing further research methods could help to obtain a more in-depth understanding of the functioning of a complex system and reasons behind student perceptions. This would inform intervention design to a greater extent in a manner consistent with CAS thinking.

3.5 Research methods and use of theory to understand complex