The complexity of school-based health promotion: A case of education outside the classroom (EOtC)

Background

Schools are key settings for health promotion, yet integrating health-promoting initiatives into teaching without competing with academic priorities remains challenging. Education outside the classroom (EOtC) embeds movement, social interaction, and authentic learning environments within teaching rather than adding them alongside it.

Methods

The cluster-randomised controlled trial, MOVEOUT, investigated effects of regular EOtC on pupils’ well-being, school motivation, and learning over one year in 20 Danish schools. The per-protocol sample comprised 10 intervention classes and 14 wait-list control classes (pupils aged 10-15 years). After a two-day training course, teachers implemented curriculum-based EOtC for ≥5 hours weekly. Outcomes were well-being, school motivation, and learning (mathematics, reading), measured at baseline and follow-up. Acute well-being and motivation were assessed in the intervention group on regular and EOtC school days. Linear mixed models were used for analysis.

Results

No significant associations were observed for school motivation or well-being, but EOtC was associated with improved learning (mathematics: 0.35, 95% CI 0.07-0.63; reading: 0.61, 95% CI 0.06-1.15). In the intervention group, EOtC days were associated with higher acute well-being and motivation compared with regular school days. Subgroup analyses suggested older pupils (aged 13-15) reported greater relative autonomy (RAI: 1.03, 95% CI 0.13-1.93).

Conclusions

Overall improvements in well-being and motivation were not observed, but EOtC supported academic learning and fostered greater day-to-day well-being and motivation on days with EOtC. These findings illustrate the complexity of school-based health promotion and the challenge of translating immediate positive experiences into long-term health outcomes. Future school-based initiatives should focus on intervention dose and pathways linking educational practice to well-being, motivation, and learning.

Key messages

• EOtC is an approach to school-based health promotion that supports learning.

• Health-promoting effects may be contextual and immediate, highlighting the complexity of school-based interventions.