Testing the zero-sum game hypothesis: an examination of school health policy and practice and inequalities in educational outcomes

Background: There is recognition that health and education are intrinsically linked, through for example the World Health Organizations' Health Promoting Schools' (HPS) framework. Nevertheless, promoting health via schools is seen by some as a 'zero-sum game'; that is, schools have nothing to gain, and in fact may experience detriments to the core business of academic attainment as a result of focussing resources on health. Crucially, there is a paucity of evidence around the impacts of health and well-being policy and practice on attainment, with recent Cochrane reviews highlighting this gap. This study explored the 'zero-sum game' hypothesis among schools with varying levels of deprivation; that is, the role of health and wellbeing interventions in schools in reducing, or widening, socioeconomic inequality in educational attainment. Methods: Wales-wide, school-level survey data on health policies and practices, reflective of the HPS framework, were captured in 2016 using the School Environment Questionnaire (SEQ). SEQ data were linked with routinely collected data on academic attainment. Primary outcomes included attendance and attainment at Key Stages 3 and 4. Interaction terms were fitted to test whether there was an interaction between FSM,overall HPS activity, and outcomes. Linear regression models were constructed separately for high (>15% of pupils) and low (