Studies evaluating of health interventions at schools: an integrative literature review

ABSTRACT Objective: to identify and analyze the available evidence on the strategies used in the studies evaluating health interventions at school. Method: this is an integrative review searching in LILACS, CINAHL, CUIDEN, ScienceDirect, and PubMed. From the pre-defined inclusion and exclusion criteria, there were 121 articles chosen to compose the sample. Results: english studies (97.5%), with a quantitative approach (80.2%), related to the interventions carried out in the Region of the Americas (54.6%) and the European Region (23.1%) predominated. For the most part, they are interventions as programs (70.2%), interested in evaluating results (73.5%) from the value judgment (83.4%). Prevalence of interventions focused on efficacy, effects or impact, and activities carried out on interventions were focused on physical activity, healthy eating, sexual and reproductive health, mental health, and use of tobacco, alcohol, and other drugs. They are worked through activities of clinical monitoring, health promotion and disease prevention. Conclusion: the evidence indicates that the evaluations of health interventions in the school focus the results produced in programs through the judgment of value. The topics most addressed were healthy eating, physical activity, prevention of alcohol and other drugs, among others.


Introduction
The offering of equal and equitable education across the globe has been one of the flags raised by international organizations in encouraging children and adolescents to be enrolled in schools. Also, it is also necessary to develop health interventions so these individuals do not have the educational process interrupted under the influence of diseases and other health problems (1) .
In these spaces, it is possible to contribute to the This fact contributed to creating several experiences all over the planet. However, because they are countries with diverse economic, political, cultural, and other contextual characteristics, it is necessary to consider that these interventions can be executed based on different objectives. Also, difficulties and challenges can be found in their implementations, requiring the need to develop evaluative processes that seek to improve them. This is possible since the evaluation has been considered as an important tool to aid the management of health interventions in the search for better answers to services resulting from improvement, resolution and better quality (5) .
The evaluations of the health interventions at school have been carried out and involve specific topics such as prevention of depression and anxiety (6) , the offering of physical activities to students (7) and drug prevention among schoolchildren (8) . No studies have been found that synthesize comprehensively the evaluation of health interventions in school in the world and its different themes.
The purpose of this study is to synthesize the studies that carried out evaluations of health interventions at school, so their strategies and the diversity of interventions directed to this space can be identified.
This will contribute to other research being carried out from the findings presented here.
The study advances knowledge as it presents the evidence on strategies used in evaluations of health interventions at school, enabling other health interventions at school to be evaluated as well.
Evaluations should be carried out by management and by health and education professionals to contribute to the promotion of health at school. It is observed by the activities developed in the daily life that the nurse performs interventions in the school environment in a continuous way.
The actions or health activities carried out in the school, such as policies, programs, projects, services, and systems, were considered an intervention. Evaluations are understood as the decision-making processes that aid in the improvement of the health interventions in the school. Therefore, there is an intimate relationship between the two, since it is not possible to evaluate interventions without knowing their organization.
In view of this information, the objective is to identify and analyze the available evidence on the strategies used in the evaluation studies of health interventions in the school.

Method
The integrative review of the literature was the   The research and selection of the studies were carried out by two researchers, simultaneously. When a situation of divergence happened, a consensus was sought with the participation of an auxiliary researcher.
The process of searching and selecting the studies followed the PRISMA recommendations (11) and is represented in Figure 1.   The analysis and discussion of the results were based on the national and international literature on school health and health evaluation.

Results
The characterization of the selected studies  included in the integrative review is presented below.
In Table 1, information regarding the year and language of publication, the approach used in these surveys and the place of execution of the interventions are observed. Information regarding the classification of the type of intervention, proposed evaluative dimension and level of evaluation performed are shown in Table 2. It was also possible to describe the interventions regarding the themes, characteristics, and typologies of evaluations proposed in their methodologies, as presented in Figure 2.
Thus, the data show that the evaluation of effects, efficacy, and impact was the most prevalent among the types of evaluation found.

It is observed that interventions of various themes
have been carried out in the school environment, whether they are in a broader theme, such as activities that aim to encourage healthier lifestyles or more specific themes such as those that prevent accidents from occurring among learners.

Discussion
The high number of studies that integrated the integrative review shows the possible concern of the researchers in offering quality interventions in the school environment, which can be done when submitting them to the evaluation processes. However, a smaller number of publications were observed in the last two years of the analysis, which can be explained by the inclusion of a year still in progress during the review period.
The predominance of studies published in the English language reflects the fact that this is a widely disseminated language in the world. Therefore, it was considered by the scientific community as a universal language to contribute to the dissemination of publications in the world and to promote better When analyzing the types of approaches used in evaluative surveys of health interventions at school, it was identified that most of them used exclusively the quantitative approach. In contrast, there were studies that proposed qualitative analysis. However, this type of research requires the appropriation of several means to understand the problems, which is possible with the integration of these two types of approaches (136) .  try to judge the merits of the interventions. In the fourth generation, there is an evaluation that advocates the participatory negotiation process among the different participants in the intervention (13) .
The fourth-generation evaluation can be carried out in school health interventions, since they have activities that allow the participation not only of the students but also of teachers, other school workers, health professionals, parents or responsible for the students in their proposals, as well as representatives of the community in which the schools are inserted (140) .
Regarding the themes in which these interventions were proposed, similar results were observed in a study The diversity of the themes and the characteristics related to health interventions at the school evaluated is essential in changing habits for the life of the students and the community where they live. This is identified in a study that shows that, these activities are of great importance to the health of the population although they seem small actions in face of the diversity of needs found (141) .
It should be emphasized that the limitations of this research were related to the high number of studies eligible for an integrative review, although the criteria chosen were delimited. Also, it is observed that the use of more than one researcher for data analysis may influence the presented results, although they were able to perform this activity.

Conclusions
The evidence found in the studies show that school health programs are the most commonly evaluated interventions, especially at the value judgment level.
These studies are mainly focused on evaluating the results produced by the interventions, corroborated in the typologies of impact, effects, efficacy, and results.