The Moderating Role of the School Context on the Effects of the Healthy Primary School of the Future

Nina Bartelink*, Patricia van Assema, Maria Jansen, Hans Savelberg, Stef Kremers

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: The current study investigated the moderating role of the school context on the effects of a Dutch health promoting school initiative on children's health and health behaviors. Methods: The study used a mixed-methods design. The school context (n = 4) was assessed by the characteristics of the school population, teacher's health-promoting (HP) practices, implementers' perceived barriers, school's HP elements, and dominating organizational issues. Outcomes included objectively assessed BMI z-scores and physical activity (PA), and parent and child-reported dietary intake. Analyses included linear mixed models (four intervention schools versus four control schools), and qualitative comparisons between intervention schools with similar HP changes. Results: Effects on outcomes varied considerably across schools (e.g., range in effect size on light PA of 0.01-0.26). Potentially moderating contextual aspects were the child's socioeconomic background and baseline health behaviors; practices and perceived barriers of employees; and organizational issues at a school level. Conclusions: Similar HP changes lead to different outcomes across schools due to differences in the school context. The adoption of a complex adaptive systems perspective contributes to a better understanding of the variation in effects and it can provide insight on which contextual aspects to focus on or intervene in to optimize the effects of HP initiatives.

Original languageEnglish
Article number2432
Pages (from-to)1-19
Number of pages19
JournalInternational Journal of Environmental Research and Public Health
Issue number13
Publication statusPublished - 1 Jul 2019


  • complex adaptive systems
  • health promoting schools
  • mixed-methods design
  • moderators
  • qualitative comparison
  • quasi-experimental design
  • school context

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