Peer-reviewed article

School-Based Educational Interventions for Improving Knowledge of Back Health, Ergonomics and Postural Behaviour of School Children Aged 4-18 Years: A Best Evidence Systematic Review.

Bettany-Saltikov J, Mcsherry R, Duangkaew R, Kandasamy G, Aristegui Racero G et al. · 15 May 2026

Abstract

Background Musculoskeletal and back health of school aged children is a global health problem, with evidence that the prevalence of these problems is increasing. Many modern school systems require children to assume sedentary positions for extended periods of time, and the increasing use of classroom-based technology adds to the number of hours seated. With the incidence of musculoskeletal pain reported not only in adult populations but increasingly in young people, an understanding of spinal health and posture may be essential for students. Objectives The main objective for conducting this review was to conduct a best evidence systematic review. This means we only included the highest quality papers on the effectiveness of school-based education programs on back health for improving knowledge of back health, ergonomics and postural behaviour in school children aged 4-18 years. Search methods We searched the following 21 electronic databases from inception till the 20th January 2023: AMED (EBSCOhost), APA PsycINFO (EBSCOhost), Best Evidence Medical Education (BEME) (EBSCOhost), British Education Index (EBSCOhost), CINAHL (EBSCOhost), Cochrane Central Register of Controlled Trials (Wiley), EMBASE (Ovid), ERIC (EBSCOhost), EThOS (British Library), Europe PMC (Europepmc.org), GoogleScholar. Health Technology Assessment (HTA) (INAHTA), Health Management Information Consortium (HMIC) (Ovid), MEDLINE (EBSCOhost), PEDro (pedro.org.au), ProQuest Dissertations & Theses (Proquest), ProQuest Nursing and Allied Health Database (ProQuest), SCOPUS (Elsevier), SportDISCUS (EBSCOhost), Web of Science (Arts and Humanities Citation Index, Science Citation Index Expanded, Social Sciences Citation Index, Emerging Sources Citation Index, Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Sciences and Humanities; Clarivate), ZEToC (British Library). Selection Criteria. Population The population eligible for the review included all children and young people between 4 and 18 years of age, attending school. Exclusion criteria: Children under 4 years of age and adults over 18 years of age; chronic disease or conditions or co-morbidities. Intervention Studies needed to meet the following criteria to be included: any formal educational school-based programme that included back health, ergonomics and postural behaviour that was designed to support the educational performance of students' knowledge of posture and ergonomics within an educational establishment. We excluded physical activity or exercise only interventions. Comparison Included studies were required to have a control group that represented either business-as-usual (no intervention), or a wait-list design. Outcomes We included studies that examined back care knowledge, knowledge of back care ergonomics, back care behaviours and knowledge of back posture. Types of research design This was a Best Evidence Systematic Review and only research papers scoring a "good" or "excellent "on the Downs and Black (1998) risk-of-bias form were included. The following research designs were included: randomised controlled trials (RCTs), cluster randomised controlled trials (CRCT) and quasi-randomised controlled trials (QRCTs). We included prospective non-randomised studies (NRSs) with a control group because it was anticipated that very few RCTs would be found. Controlled before-after studies (CBAs), interrupted time series (ITS) studies as well as controlled studies that were non-randomised and included a pre- and post-test were also eligible for inclusion. Data collection and analysis Titles and abstracts were screened in duplicate. Full texts of studies with seemingly relevant abstracts were retrieved and assessed for eligibility using the pre-specified inclusion criteria. Full texts were also screened in duplicate. Studies were classified as either included or excluded. Two authors independently extracted data from relevant studies. Main results 1,327 potentially relevant papers were found through the searches of the academic databases, while no studies were identified through searches of grey literature and reference lists. After removing 1,256 articles which did not meet the inclusion criteria, 71 studies remained for screening. 37 articles were excluded based on screening the titles and abstracts. This left 34 articles for further examination of full texts. After the full texts had been read, these 34 studies continued to the quality assessment/risk of bias stage using the Downs and Black ROB form. Only two papers scored 20 or over (i.e. good or excellent) and were included in this systematic review. As the outcomes of the two studies differed, it was not possible to conduct a meta-analysis. Therefore, a narrative synthesis was conducted. Each of these studies showed statistically significant improvements on knowledge and behaviour, in the short term (3-8 months) though these need to be interpreted in light of concerns regarding risk of bias. Authors conclusions Despite the comprehensive search of electronic databases, grey literature, hand searching, journals and reference lists of included studies, we only found two 'good' quality studies (scoring 20-25). No studies achieved an "excellent" score, that provided "excellent" evidence, on the effectiveness of school-based education programs on back health for improving knowledge of back health, ergonomics and postural behaviour in school children aged 4-18 years. This highlights the urgent need for high-quality studies to be conducted to assess the effects of these programmes due to the importance of ergonomics and posture in the activities of daily living of school children.