Healthy for Life Pilot Study: A Multicomponent School and Home Based Physical Activity Intervention for Disadvantaged Children

The study aimed to develop and evaluate a multicomponent school and home based physical activity (PA) intervention in children in grades 3–7 (aged 8–13 years) and determine the psychological variables that influence PA; 10 × 1 h school-based training sessions, a home-based activity program and 4 × 1 h lifestyle workshops for parents. PA was assessed at an intervention and nearby control school using accelerometers and self-report at 3-time points: baseline, post intervention and 10-week follow-up. Self-efficacy, self-management strategies, enjoyment, perceived barriers to PA, outcome-expectancy and social support were evaluated. The study showed 73% of the children with complete data sets at the intervention school (n = 27) did not increase device measured moderate to vigorous PA (MVPA) in the after-school period (3 p.m. to 6 p.m.) or over the whole day or during school break time immediately following the intervention or at follow-up, as compared to 70% of children with complete data sets at the control school (n = 35; p > 0.05 for all). Overall, 59% of boys attained more than double the recommended 120 min of MVPA each day compared to 42% of girls (p = 0.013). At the baseline, children’s self-reported PA in the intervention school positively correlated with: outcome expectancy (R = 0.240, p = 0.015), enjoyment (R = 0.339, p < 0.001), self-efficacy (R = 0.399, p < 0.001), self-management (R = 0.617, p < 0.001), social support at home (R = 0.406, p < 0.001), and social support at school (R = 0.407, p < 0.001). Similar relationships were observed after the intervention and at follow-up. Focus groups with the children, parents and interviews with teachers identified areas for improvement of the intervention. In conclusion, while the multifaceted approach to improve PA was ineffective over the time span of the study, important predictors of PA in this sample of disadvantaged children were identified.

School-Based Mental Health Promotion and Prevention Program "Turn 2 Us" Reduces Mental Health Risk Behaviors in Urban, Minority Youth

BACKGROUND

Turn 2 Us (T2U) is an elementary school-based mental health promotion and prevention program in New York City. It targets fourth- and fifth-grade students at risk for social/emotional and behavioral problems and provides a range of services to students, staff, and parents. The purpose of this study is to determine if T2U decreases internalizing and externalizing behaviors in participating students.

METHODS

Teachers measured students' symptoms before and after participation using the strengths and difficulties questionnaire (SDQ). Change in the total SDQ score was analyzed using Wilcoxon rank-sum nonparametric testing. We assessed the effects of covariates on the score change with linear regression models.

RESULTS

The 185 unique students who participated in the intervention showed a significant improvement in total SDQ score (Z = -4.107, p < .001). Students who were at higher risk prior to the intervention showed greatest improvement in behaviors. None of the covariates assessed affected the change in SDQ score. Regression models showed that higher initial SDQ scores predicted higher post-intervention SDQ scores (β = 0.681, p < .001).

CONCLUSION

T2U significantly decreased internalizing and externalizing behaviors in participating students, with the greatest impact for highest risk students. This study helps validate T2U's unique and comprehensive approach.

Protocol for systematic reviews of school-based food and nutrition education intervention for adolescent health promotion: Evidence mapping and syntheses

BACKGROUND

Nutrition is an important modifiable factor in combating overweight and obesity among adolescents. School has been indicated as an effective environment for influencing eating behavior; however, recent reviews assessing school-based interventions specifically for adolescents are scarce. Therefore, we propose the present systematic review with the aim to comprehensively review the quantitative and qualitative literature on the effects of school-based food and nutrition education interventions on adolescent health promotion through healthy eating habits.

METHODS

We will search MEDLINE/PubMed, Embase, Scopus, ERIC, ScienceDirect, Web of Science, Cochrane, LILACS, and ADOLEC. We will include randomized controlled trials (RCT), non-RCT, and controlled before-after studies. Risk of bias will be assessed using the EPOC Risk of Bias Tool for RCT, Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool for non-RCT or controlled before-after, as well as the Critical Appraisal Skills Program (CASP) checklist for qualitative studies. We will analyze the overall strength of the evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. Two independent researchers will conduct all evaluations and any disagreements will be consulted with a third reviewer. Data analysis and synthesis will be analyzed by the RevMan 5.3 software. We will conduct the study in accordance with the guideline of the Preferred Reporting Items for Systematic Review and Meta-analyses Protocols.

RESULT

This review will evaluate the effects of school-based food and nutrition education interventions on adolescent health promotion through healthy eating habits. The primary outcome will be changes in adolescent food consumption. Secondary outcomes will be biological parameters (e.g., body mass index (BMI), waist circumference (WC), body composition, etc); biochemical parameters (e.g., glycemia, triglycerides, total cholesterol, etc); qualitative evidences that support or explain the effect of school-based food and nutrition education interventions on adolescent food consumption.

CONCLUSION

The findings of this systematic review will summarize the latest evidence of the effects of school-based food and nutrition education interventions on adolescent health promotion. The findings will be an available reference for school-based interventions and other further research.

REGISTRATION

PROSPERO CRD42019116520.

Economic evaluation of a childhood obesity prevention programme for children: Results from the WAVES cluster randomised controlled trial conducted in schools

Background

Childhood obesity is a serious public health challenge and schools have been identified as an ideal place to implement prevention interventions. The aim of this study was to measure the cost-effectiveness of a multi-faceted school-based obesity prevention intervention targeting children aged 6–7 years when compared to ‘usual activities’.

Methods

A cluster randomised controlled trial in 54 schools across the West Midlands (UK) was conducted. The 12-month intervention aimed to increase physical activity by 30 minutes per day and encourage healthy eating. Costs were captured from a public sector perspective and utility-based health related outcomes measured using the CHU-9D. Multiple imputation using chained equations was used to address missing data. The cost effectiveness was measured at 30 months from baseline using a hierarchical net-benefit regression framework, that controlled for clustering and prespecified covariates. Any uncertainty in the results was characterised using cost-effectiveness acceptability curves.

Results

At 30 months, the total adjusted incremental mean cost of the intervention was £155 (95% confidence interval [CI]: £139, £171), and the incremental mean QALYs gained was 0.006 (95% CI: -0.024, 0.036), per child. The incremental cost-effectiveness at 30 months was £26,815 per QALY and using a standard willingness to pay threshold of £30,000 per QALY, there was a 52% chance that the intervention was cost-effective.

Conclusions

The cost-effectiveness of the school-based WAVES intervention was subject to substantial uncertainty. We therefore recommend more research to explore obesity prevention within schools as part of a wider systems approach to obesity prevention.

Trial registration

This paper uses data collected by the WAVES trial: Controlled trials ISRCTN97000586 (registered May 2010).

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

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.

School-wide implementation of positive behavioral interventions and supports in an alternative school setting: A case study

AIMS

The purpose of this 1-year case study was to identify how School-Wide Positive Behavioral Interventions and Supports (SW-PBIS) can be adapted to meet the needs of students in alternative schools and to evaluate the early impact of SW-PBIS on discipline outcomes.

METHODS

Suggestions for adaptations are provided at each stage of the intervention process with a focus on buy-in, training, data collection, and resource allocation.

RESULTS

Data from this case study included information about key components of the implementation process as well as initial outcomes. Process data revealed the importance of stakeholder buy-in, training opportunities, and potential adaptations to the framework. Outcome data from the first year of implementation indicated that the number of incident reports did not significantly differ from the baseline; however, there was a reduction in defiance-related behaviors and an increase in on-task behaviors.

CONCLUSION

This study contributes to the determination of the efficacy of SW-PBIS in a historically more punitive environment. Given the initial positive response and lessons learned, it is believed that, with the support of additional Tier 2 and Tier 3 interventions, SW-PBIS may be an appropriate framework to support students in alternative schools.

Factors Associated with School Nurses' and Personnel's Professional Practice to Encourage Parents to Vaccinate Against Human Papillomavirus

BACKGROUND

School nurses and personnel play a vital role in promoting the human papillomavirus (HPV) vaccine. The purpose of this study was to identify factors associated with school nurses' and personnel's professional practice to provide parents with HPV vaccine information and to encourage parents to vaccinate their child against HPV.

METHODS

School nurses and personnel from Ohio and Missouri completed a survey to assess their professional practice in providing HPV vaccine information and encouraging parents to vaccinate their child against HPV. Independent variables included demographics, HPV knowledge/attitudes, perceptions of their as an opinion leader for the HPV vaccine, self-efficacy to provide vaccine education, and perception of school district support.

RESULTS

Providing parents with HPV vaccine information was predicted by age, role within the school, grade-serving, knowledge, perceptions, self-efficacy, and district support; accounting for 38% of the variance (p < .000, R²  = .38). Encouraging parents to vaccinate their child against HPV was predicted by perception, self-efficacy, and grade-serving; accounting for 39% of the variance (p < .000, R²  = .39).

CONCLUSIONS

To enhance school nurses' and personnel's professional practice, interventions should focus on nurses' and personnel's perception of their role as opinion leaders and self-efficacy to provide HPV education and vaccine recommendation.

Developing and Piloting a School-Based Online Adolescent Student-Athlete Concussion Surveillance System

BACKGROUND

Despite increased awareness of concussions, epidemiologic surveillance efforts have been scarce, especially among adolescents. This project, which was developed with school stakeholders (certified athletic trainers [ATCs], nurses, athletic directors), piloted a public secondary school-based online surveillance tool for interscholastic and intramural sports and physical education-related concussions in New Jersey during 2014-2017 school years (SY).

METHODS

Participating public high schools (5 within 4 districts) and career-technical-vocational education districts (2 with 5 campuses) completed forms anonymously online via PsychData within 5 days.

RESULTS

There were 208 concussions reported, 115 in 2015-2016 SY and 93 in 2016-2017 SY. In fall 2015, 86 concussions were reported, including 16 from summer preseason. In fall 2016, 56 concussions were reported; 3 occurred during preseason. There were 7 concussions reported in winter 2016 and 16 in winter 2017. Twenty-two concussions were reported in spring of both 2016 and 2017. Most online forms were completed in <10 minutes, usually using either desktop computers or tablets/iPads. School nurses followed by ATCs were primary sources of data entered online, usually by ATCs.

CONCLUSIONS

Cooperation of nurses and ATCs at participating schools suggested online surveillance was valued and viable. Data inform future concussion prevention education and ongoing injury surveillance.

Food Safety Education Needs of High-School Students: Leftovers, Lunches, and Microwaves

BACKGROUND

We explored priority areas of food safety education needed by high-school students within Ontario, Canada.

METHODS

We analyzed transcripts from semistructured interviews with 20 experts in food safety, food safety education in youth, and high-school education in Ontario. Inductive thematic analysis was used to identify priority food safety education needs.

RESULTS

We identified 4 priority action areas for food safety education targeting students: how to safely do the things they typically do with food; how to keep themselves and their kitchens clean and safe; how microorganisms grow and how they can result in foodborne disease; and how to keep food out of the "danger zone" 4°C to 60°C (40° F to 140° F). The results indicate that students need specific education around the use of microwaves, consumption of convenience meals, preparing and handling foods at school events, and safe transportation of food for lunches, school trips, and sporting events.

CONCLUSIONS

High-school students need food safety education specific to their usual interactions with food, including the foods, tools, and settings students regularly encounter. Delivery of food safety education should emphasize sequences of safe food-handling behaviors for specific food interactions, such as reheating a meal in the microwave, rather than traditional food safety concepts, such as temperature abuse.

Using a Modified Theory of Planned Behavior to Examine Teachers' Intention to Implement a Work Safety and Health Curriculum

BACKGROUND

Workplace safety and health is a major public health concern, but largely absent from the school health curriculum. Little is known about teachers' perceptions of teaching workplace safety and health topics.

METHODS

We administered a 41-item questionnaire reflecting the theory of planned behavior, modified to measure knowledge, to 242 middle and high school teachers in career and technical education and academic subjects. We conducted confirmatory factor analysis to assess the measures' psychometric properties and factorial ANOVAs to compare differences among participants' knowledge, attitude toward, self-efficacy, and intention (to teach) workplace safety and health by sex, prior work injury, and main subject taught.

RESULTS

Confirmatory factor analyses indicated the measures reflected the theory. Factorial ANOVAs suggested female teachers had statistically significantly lower mean self-efficacy scores than did male teachers to teach workplace safety and health. Male occupational career and technical education teachers demonstrated higher mean knowledge scores than male teachers in other subjects. Participants not injured at work had higher knowledge scores than those who had been injured.

CONCLUSION

Self-efficacy (influenced by sex) and knowledge (influenced by subject taught and previous workplace injury) revealed factors that may affect teachers' provision of workplace safety and health education, a critical yet overlooked component of school health.

A Social Gradient in the Effects of the Skills for Life Program on Self-Efficacy and Mental Wellbeing of Adolescent Students

BACKGROUND

The goal of the current study was to evaluate the effects of the Social Emotional Learning program Skills 4 Life on mental health and its risk factors self-esteem, self-efficacy, and social interaction skills in students of secondary schools.

METHODS

A cluster randomized controlled study was conducted, including 38 schools (66 classes; grades 7 to 9) for secondary education, with a 1 year and 20 months follow-up (teachers and students reports).

RESULTS

The intervention was effective in improving self-efficacy, depressive symptoms, and teacher-reported psychological problem behavior, all after 20 months. Stratified analyses showed effects in mainly lower educational level students.

CONCLUSION

The Skills 4 Life curriculum is effective in improving the mental health and self-efficacy among adolescents, especially for adolescents from lower educational level, a group that is most prone to ill mental health.

The Essential Elements of Adolescent-friendly Care in School-based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents

PURPOSE

In this study we identified the essential elements of adolescent-friendly care in school-based health centers (SBHCs) from the perspectives of the nurse practitioners (NPs) providing care to adolescents and the adolescents, as the consumers of these services.

DESIGN AND METHODS

Complex adaptive systems provided the philosophical and theoretical foundation for this study. An explanatory sequential mixed methods study was conducted. A Delphi technique (strand one) was conducted with an expert panel of NPs (N = 21) to identify the essential elements of adolescent-friendly care in SBHCs. The second strand, a focus group study with adolescents (N = 30), elaborated on the Delphi results. Data from the two strands were then mixed.

RESULTS

This study generated expert opinion regarding the essential elements of adolescent-friendly health care in SBHCs. After four Delphi rounds, consensus was reached on 98-items (49% of the original 200; consensus level of 0.75). The results clustered into 6 essential elements: Confidentiality/Privacy (n = 8; 8.2%), Accessibility, (n = 15; 15.3%), Clinician/Staff (n = 51; 52%), SBHC Clinical Services (n = 12; 12.2%), SBHC Environment (n = 4; 4.1%), and Relationship between the School and SBHC (n = 8; 8.2%). The adolescent focus groups confirmed the essential elements identified in the Delphi and added two overarching themes: Comfortable and Trusted Relationship.

CONCLUSIONS

These findings contribute to a greater understanding of essential characteristics needed in adolescent friendly care.

PRACTICE IMPLICATIONS

SBHCs, as an important community resource for addressing the health care needs of adolescents, should incorporate these characteristics.

Background and evaluation design of a community-based health-promoting school intervention: Fit Lifestyle at School and at Home (FLASH)

BACKGROUND

A community-based approach can be a promising strategy for implementing school-based health promotion aimed at stimulating healthy physical activity and dietary behaviour. Such an approach builds on the community capacity of multiple stakeholders, empowering them to design and implement tailored activities, supported by the whole school community. This paper describes the background and evaluation design of the community-based school intervention 'Fit Lifestyle at School and at Home' (FLASH) in four prevocational schools. FLASH includes four strategies for building the community capacity of students, school personnel and parents: 1) identifying leaders in each stakeholder group, 2) stimulating a school culture of participation, 3) having stakeholders design and implement tailored activities and 4) creating a network of local partners for structural embedding. The objective is to monitor the capacity-building processes of the FLASH intervention and to explore if these processes contribute to changes in community capacity. In addition, we will explore if the FLASH intervention is related to changes in PA, dietary behaviours and BMI of students.

METHODS

This study has a mixed methods design and uses a participatory action-oriented approach to monitor and evaluate changes in community capacity, tailored health-promotion activities and implementation processes. Methods include semi-structured interviews, focus groups, journals, document analysis and observational scans of the physical environment. In addition, changes in BMI, physical activity and dietary behaviours of prevocational students will be explored by comparing the four intervention schools to four control schools. Data are collected by questionnaires and anthropometric measurements.

DISCUSSION

The main strength of this study is its use of mixed methods to evaluate real-life processes of creating a healthy-school community. This will provide valuable information on capacity-building strategies for the structural embedding of health-promotion activities within school settings. The results could help schools become more empowered to adapt and adopt integral health-promotion interventions in daily practice that suit the needs of their communities, that are expected to be sustainable and that could lead to favourable changes in the PA and dietary behaviour of students.

TRIAL REGISTRATION

ISRCTN67201841 ; date registered: 09-05-2019, retrospectively registered.

Implementation of a peer-led school based smoking prevention programme: a mixed methods process evaluation

BACKGROUND

Smoking prevention programmes that reach adolescents before they experiment with tobacco may reduce the prevalence of tobacco use. ASSIST is a school-based, peer-led smoking prevention programme that encourages the diffusion of non-smoking norms among secondary school students (aged 12-13), and was shown in a randomised control trial (conducted 2001-2004) to reduce the prevalence of weekly smoking. This paper presents findings from a process evaluation of the implementation of ASSIST in Scotland in 2014-2017. It examines acceptability and fidelity of implementation and explores the context of message diffusion between peers.

METHODS

Mixed method implementation study with students (n = 61), school staff (n = 41), trainers (n = 31) and policy and commissioning leads (n = 17), structured observations (n = 42) and student surveys (n = 2130).

RESULTS

ASSIST was delivered with a high degree of fidelity to the licensed manual with all elements of the programme implemented. Student survey findings indicated that the frequency of conversations about smoking increased over the ASSIST delivery period (18% at baseline, 26% at follow-up), but student recollection of conversations about smoking with peer supporters was low (9%). The delivery context of ASSIST was important when considering perceptions of message diffusion. In the study schools, survey findings showed that 0.9% (n = 19) of participants were regular smokers (at least once a week), with nine out of ten (89.9%, n = 1880) saying they had never smoked. This very low prevalence may have affected when and with whom conversations took place. Study participants indicated that there were wider benefits of taking part in ASSIST for: peer supporters (i.e. personal and communication skills); schools (an externally delivered health promotion programme that required minimal resource from schools); and communities (via communication about the risks of smoking to wider social networks).

CONCLUSIONS

ASSIST in Scotland was delivered with a high degree of fidelity to the licensed programme and was acceptable from the perspective of schools, students and trainers. Targeting ASSIST in deprived areas with higher youth smoking prevalence or in other countries where youth smoking rates are rising or higher than in Scotland may be particularly relevant for the future delivery.

An observational study of adolescent health outcomes associated with school-based health service utilization: A causal analysis

OBJECTIVE

Our aim is to examine the unbiased association between use of school-based health services (SBHS) and student health outcomes.

DATA SOURCES

Data are from a nationally representative health and well-being survey of 8500 New Zealand high school students from 91 high schools.

STUDY DESIGN

Student data were linked to the level of SBHS available to them: no SBHS, regular clinics from visiting health professionals, a health professional onsite, or a health team onsite.

DATA COLLECTION/EXTRACTION METHODS

Causal analyses are used to compare utilization of SBHS and their association with student-reported health outcomes, including foregone health care, depressive symptoms, emotional and behavioral difficulties, suicide risk, substance use, and unsafe sexual behaviors.

PRINCIPAL FINDINGS

Results from the multinomial propensity score-weighted regressions show that the use of SBHS was associated with poorer health outcomes, suggesting that selection bias was present due to unmeasured confounders. Instrumental variable analyses found that that students using team-based SBHS had a 4.7 percent (95% CI 0.5-8.9) probability of high levels of depressive symptoms compared to 14.2 percent (95% CI 11.5-16.8) among students not using team SBHS. For suicide attempt, students using team-based SBHS had a 2.0 percent (95% CI -0.3-4.2) probability of a suicide attempt in the previous 12 months compared to 5.6 percent (95% CI 2.6-8.5) among students not using team SBHS.

CONCLUSIONS

These analyses suggest that team-based SBHS are associated with better mental health among students who attend them.

School Wellness in Wisconsin: Evaluating Policies for Practices to Prevent Pediatric Obesity

BACKGROUND

We examined written language in Wisconsin school wellness policies (SWPs) for federal mandate compliance, quality related to obesity prevention, and school characteristics associated with variations in quality. This is the first near census of Wisconsin SWPs and examines whether adhering to federal mandates results in strong policies aimed at preventing pediatric obesity.

METHODS

Policies were coded using the WellSAT 2.0. Policy quality was computed as comprehensiveness and strength based on 6 subscales and 2 overall scores. Variations in policy quality were examined by district size, free/reduced lunch percentage, and year of last revision.

RESULTS

We received SWPs from 91% of districts. Six of the 8 federal mandates were addressed by the majority of districts, although less than one fourth addressed all. Most comprehensiveness scores were weak to moderate, and strength scores were weak. All school characteristics were significantly related to overall policy quality; effect sizes were small.

CONCLUSIONS

Our results confirm the necessity of statewide focus on SWP improvement and suggest that while districts may be meeting federal mandates related to pediatric obesity, few policies include health promotion practices beyond those required. Policies remain fragmented and lack focus on obesity prevention practices; we identify modifiable areas for improvement.

Medical School Strategies to Address Student Well-Being: A National Survey

PURPOSE

To describe the breadth of strategies U.S. medical schools use to promote medical student well-being.

METHOD

In October 2016, 32 U.S. medical schools were surveyed about their student well-being initiatives, resources, and infrastructure; grading in preclinical courses; and learning communities.

RESULTS

Twenty-seven schools (84%) responded. Sixteen (59%) had a student well-being curriculum, with content scheduled during regular curricular hours at most (13/16; 81%). These sessions were held at least monthly (12/16; 75%), and there was a combination of optional and mandatory attendance (9/16; 56%). Most responding schools offered a variety of emotional/spiritual, physical, financial, and social well-being activities. Nearly one-quarter had a specific well-being competency (6/27; 22%). Most schools relied on participation rates (26/27; 96%) and student satisfaction (22/27; 81%) to evaluate effectiveness. Sixteen (59%) assessed student well-being from survey data, and 7 (26%) offered students access to self-assessment tools. Other common elements included an individual dedicated to overseeing student well-being (22/27; 82%), a student well-being committee (22/27; 82%), pass/fail grading in preclinical courses (20/27; 74%), and the presence of learning communities (22/27; 81%).

CONCLUSIONS

Schools have implemented a broad range of well-being curricula and activities intended to promote self-care, reduce stress, and build social support for medical students, with variable resources, infrastructure, and evaluation. Implementing dedicated well-being competencies and rigorously evaluating their impact would help ensure appropriate allocation of time and resources and determine if well-being strategies are making a difference. Strengthening evaluation is an important next step in alleviating learner distress and ultimately improving student well-being.

School Health Program: Impacting Physical Activity Behaviors Among Disadvantaged Students

BACKGROUND

Children from disadvantaged backgrounds are more apt to experience lower availability of nutritious foods, lack opportunities to exercise, and lack access to recreational facilities, and thus, are more likely to be obese and at greater risk for developing chronic diseases. We review school health education programs' impact on physical activity behaviors among disadvantaged students.

METHODS

The inclusion criteria of the study were articles: published in English with full text between 2011 and 2017; focused on school health education programs for disadvantaged school-aged students; assessed programs including a physical activity component; examined school-aged children and adolescents' physical activity behaviors; and assessed programs with comparison groups.

RESULTS

There were 13 studies matching inclusion criteria in this review. The results of this review indicated that school-based health education programs which included culturally appropriate physical activity, parent involvement, and enhanced student motivation and choice of activities appeared to increase physical activity levels among disadvantaged school-aged students. Health education programs should also emphasize behavioral change skills, such as goal setting and self-motivation, to positively impact on students' physical activity behaviors.

CONCLUSIONS

School-based health education programs may help increase access to physical activity among disadvantaged populations.

Teachers' Perspectives on Creating an Inclusive Climate in Middle School Physical Education for Overweight Students

BACKGROUND

Establishing and maintaining a positive, inclusive social climate in school is essential, especially given the many potential social pressures that make school a toxic environment for vulnerable students. We explored middle school physical education (PE) teachers' perceptions of the factors that influence the implementation of social-oriented approaches to include overweight and obese students.

METHODS

We used a qualitative multicase study design guided by the Social Ecological Constraints model to study 9 PE teachers' perspectives and actions. We analyzed the transcripts of semistructured interviews, field notes, and artifacts related to teaching, PE programs, and school policies. Trust was established in conventional ways.

RESULTS

Social-ecological factors influenced teachers including program and school culture, policies, and norms of collaboration. Teachers acted beyond their instructional setting level strategies and used school-program level strategies to socially include overweight and obese in PE.

CONCLUSIONS

Some environments challenge employment of more than simple accommodations and a caring attitude; in others, teachers can collaborate with other school personnel to teach social goals through negotiating constraints, creating ingenious modifications and interactive tasks, and incorporating personal and social skills as a primary curricular goal.

The influence of a blended, theoretically-informed pre-implementation strategy on school-based clinician implementation of an evidence-based trauma intervention

BACKGROUND

Individual-level implementation determinants, such as clinician attitudes, commonly influence the successful adoption of evidence-based practices, but few explicit strategies have been tested with regard to their ability to impact these key mechanisms of change. This paper reports on an initial test of a blended, theoretically informed pre-implementation strategy designed to target malleable individual-level determinants of behavior change. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a brief and pragmatic pre-implementation strategy that uses strategic education, social influence techniques, and group-based motivational interviewing to target implementation attitudes, perceived social norms, perceived behavioral control, and behavioral intentions to implement among mental health clinicians working in the education sector.

METHODS

As part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma (the Cognitive Behavioral Intervention for Trauma in Schools). Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and 4-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked.

RESULTS

A series of regression models and independent sample t tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At 4-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls.

CONCLUSION

Findings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03791281 . Registered 31 December 2018-Retrospectively registered.

School-based physical activity intervention for older adolescents: rationale and study protocol for the Burn 2 Learn cluster randomised controlled trial

INTRODUCTION

This trial aims to investigate the impact of a school-based physical activity programme, involving high-intensity interval training (HIIT), on the physical, mental and cognitive health of senior school students.

METHODS AND ANALYSIS

The Burn 2 Learn (B2L) intervention will be evaluated using a two-arm parallel group cluster randomised controlled trial with allocation occurring at the school level (to treatment or wait-list control). Schools will be recruited in two cohorts from New South Wales, Australia. The trial will aim to recruit ~720 senior school students (aged 16-18 years) from 20 secondary schools (ie, 10 schools per cohort). A range of implementation strategies will be provided to teachers (eg, training, equipment and support) to facilitate the delivery of HIIT sessions during scheduled classes. In phase I and II (3 months each), teachers will facilitate the delivery of at least two HIIT sessions/week during lesson-time. In phase III (6 months), students will be encouraged to complete sessions outside of lesson-time (teachers may continue to facilitate the delivery of B2L sessions during lesson-time). Study outcomes will be assessed at baseline, 6 months (primary end point) and 12 months. Cardiorespiratory fitness (shuttle run test) is the primary outcome. Secondary outcomes include: vigorous physical activity, muscular fitness, cognition and mental health. A subsample of students will (i) provide hair samples to determine their accumulated exposure to stressful events and (ii) undergo multimodal MRI to examine brain structure and function. A process evaluation will be conducted (ie, recruitment, retention, attendance and programme satisfaction).

ETHICS AND DISSEMINATION

This study has received approval from the University of Newcastle (H-2016-0424) and the NSW Department of Education (SERAP: 2017116) human research ethics committees.

TRIAL REGISTRATION NUMBER

ACTRN12618000293268; Pre-results.

Introducing physically active lessons in UK secondary schools: feasibility study and pilot cluster-randomised controlled trial

OBJECTIVES

Assess feasibility, acceptability and costs of delivering a physically active lessons (PAL) training programme to secondary school teachers and explore preliminary effectiveness for reducing pupils' sedentary time.

DESIGN AND SETTING

Secondary schools in East England; one school participated in a pre-post feasibility study, two in a pilot cluster-randomised controlled trial. In the pilot trial, blinding to group assignment was not possible.

PARTICIPANTS

Across studies, 321 randomly selected students (51% male; mean age: 12.9 years), 78 teachers (35% male) and 2 assistant head teachers enrolled; 296 (92%) students, 69 (88%) teachers and 2 assistant head teachers completed the studies.

INTERVENTION

PAL training was delivered to teachers over two after-school sessions. Teachers were made aware of how to integrate movement into lessons; strategies included students collecting data from the environment for class activities and completing activities posted on classroom walls, instead of sitting at desks.

PRIMARY AND SECONDARY OUTCOMES

Quantitative and qualitative data were collected to assess feasibility and acceptability of PAL training and delivery. Outcomes were assessed at baseline and ~8 weeks post-training; measures included accelerometer-assessed activity, self-reported well-being and observations of time-on-task. Process evaluation was conducted at follow-up.

RESULTS

In the feasibility study, teachers reported good acceptability of PAL training and mixed experiences of delivering PAL. In the pilot study, teachers' acceptability of training was lower and teachers identified aspects of the training in need of review, including the outdoor PAL training and learning challenge of PAL strategies. In both studies, students and assistant head teachers reported good acceptability of the intervention. Preliminary effectiveness for reducing students' sedentary time was not demonstrated in either study.

CONCLUSIONS

No evidence of preliminary effectiveness on the primary outcome and mixed reports of teachers' acceptability of PAL training suggest the need to review the training. The results do not support continuation of research with the current intervention.

TRIAL REGISTRATION NUMBER

ISRCTN38409550.

Preventing Adolescent Substance Use: A Content Analysis of Peer Processes Targeted Within Universal School-Based Programs

Universal school-based substance use prevention programs are widely disseminated and often include a focus on peer relationships. Network theory and social network analysis (SNA) have emerged as useful theoretical and methodological frameworks for examining the role of peer relationships in prevention and intervention research. We used content analysis to systematically code the peer processes targeted by three universal school based prevention programs. We found that programs focused on peer socialization more than peer selection, and programs focused about evenly on descriptive and injunctive norms. Programs varied in their focus on positive and negative peer processes and behaviors, but most references to peer processes focused on positive processes and negative behaviors. The focus on peer processes at the dyadic, subgroup, and network levels varied across the three programs, with the heaviest focus on network level processes. When peer processes were targeted, it was rare that lessons focused on peer processes for an extended (> 50%) amount of the lesson content. However, when peer processes were a focus, discussion and reflection were commonly encouraged. These patterns are considered in the context of non-intervention research on adolescent peer relations, which highlights the importance of peer selection and dyad-level processes, and the existence of positive peer processes that promote adolescent development. In doing so, we provide a framework that can be used to (1) examine the extent to which a particular program focuses on the different peer processes, and (2) inform systematic experimental studies of the extent to which particular peer processes are malleable in response to intervention efforts.

Framework for Supporting Adolescent Peer Leaders: A Pilot Using Text Messaging in a School-Based Substance Use Prevention Program

Training peer leaders (PLs) as implementation agents is a state-of-the-art approach in prevention, but the field lacks frameworks for providing support. Text messaging, a powerful tool for direct intervention, may be useful in this regard. We introduce a conceptual framework for engaging, retaining, and educating adolescent PLs and conduct a pilot test of this framework using text messages for delivery to middle school PLs in a new, peer-led substance use prevention program. Fifty eighth-graders were recruited as PLs. We used a newly-developed framework to create text messages to strengthen peer leaders': (a) mission, agency, and team identity; (b) connection to adult mentors; (c) content knowledge and application to their own lives; and (d) preparation for prevention activities. Thirty-four texts were sent to PLs over 4 months. PL replies and participation were recorded to track engagement. Forty-one PLs (71%) received texts and completed baseline and post-program surveys. Parents and school staff completed post-program questionnaires. Eighty-five percent of PLs responded to at least one text message. Response rates for specific messages varied from 22 to 56%. Students were most likely to reply to texts about preparation for their own prevention activities in the school. Ninety-five percent of PLs said they read messages even when they did not reply. Eighty-three percent of PLs said the messages helped them accomplish their mission. PLs reported that they wanted to receive messages in the future. PL attendance had very little variability in two of the three schools, but replies to texts were associated with better attendance in one school. Our study provides a framework for supporting adolescent peer leaders in a network intervention. Automated text messaging supporting middle school PLs was feasible, engaging, and well-received. Texting activity was associated with participation in school-based activities. Future priorities include systematically varying text support to determine its true effect on implementation and on involvement by less engaged PLs.

Evaluation of a classroom movement integration training delivered in a low socioeconomic school district

Movement integration (MI), which involves infusing physical activity (PA) into general education classrooms, is an evidence-based strategy within whole-of-school approaches for helping children meet the national PA guideline of at least 60 min per day. This study evaluated an MI training delivered in a low socioeconomic elementary school that had recently invested in three movement facilitative classrooms (a kinesthetic classroom and two activity labs). We investigated (a) the training's fidelity in meeting recommended best practices for professional development and (b) school professionals' perspectives of the training. Eight school professionals participated in the study, including five classroom teachers, two activity lab supervisors, and the principal. The researchers used a video of the training to rate the fidelity of the training to best practice recommendations. Interviews, field notes, and informal conversations with participants were qualitatively analyzed for themes. The training received a total fidelity score of 42%. Qualitative findings highlighted participants' varied perspectives of the training's purpose, challenges associated with the training and future recommendations for MI trainings. For MI trainings to be a valuable asset in increasing teachers' value and effective implementation of MI, trainings need to be designed to be in line with best practice recommendations and teachers' perceived needs.

Program implementer perspectives replicating evidence based sexual reproductive health programs

PURPOSE

Explore factors affecting implementation of evidence based adolescent sexual/reproductive health programs, from the perspectives of program implementers.

METHODS

In-depth interviews were conducted with 18 program implementers delivering six sexual/reproductive health programs in New Jersey. Programs were delivered among 2698 primarily African American and Hispanic adolescents in school and community-based settings. Interview transcripts were coded and analyzed iteratively for themes by trained experts.

RESULTS

Program implementers reported weaknesses in the program curricula content and design, scheduling constraints with partner sites, and questions from adolescents as factors challenging to implementation. Relationship-building (with adolescents and community partners) and answering adolescent questions were identified as strategies to program implementation. Implementers expressed need for flexibility in the curriculum to tailor the program to participant needs. However, implementers felt restricted in tailoring the program because of a perceived need to adhere to the prescribed program.

CONCLUSIONS

Evidence based programs may need to provide more flexibility for implementers to customize programs to student needs. Given the age range of the target audience (ages 10-19), programming should consider the variance of an adolescent's life and assumptions regarding adolescent biology knowledge, modes of communication, and type of sexual relationships. Additionally, facilitators may better meet student needs if they feel less restricted.

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study

BACKGROUND

Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers' use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs-discrete trial training, pivotal response training, and visual schedules-for children with autism in special education classrooms in public elementary schools.

METHODS

Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models.

RESULTS

There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (f2 = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (f2 = .22). No organizational factors were significantly associated with implementation with any of the three EBPs.

CONCLUSIONS

Attitudes toward EBPs may affect teachers' decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP's similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

A preschool-based intervention for Early Childhood Education and Care (ECEC) teachers in promoting healthy eating and physical activity in toddlers: study protocol of the cluster randomized controlled trial PreSchool@HealthyWeight

BACKGROUND

Interventions to prevent overweight and obesity in toddlers are needed to minimize health inequalities, especially in migration and lower socio-economic groups. Preschools are identified as important environments for interventions to prevent overweight and obesity. Early Childhood Education and Care (ECEC) teachers in preschools are potential key actors in promoting healthy eating and physical activity. This paper describes the research design of a Dutch preschool-based intervention for ECEC teachers in promoting healthy eating and physical activity in toddlers.

METHODS

PreSchool@HealthyWeight concerns a cluster randomized controlled trial on preschools in Amsterdam Nieuw-West, Netherlands. This city district is characterised by inhabitants with a migration background and low socio-economic status. Forty-one preschools, with 115 ECEC teachers and 249 toddlers/parents, were randomly allocated to an intervention or control group. An intervention for teachers will be carried out on intervention locations and consists of modified versions of 2 existing programs: 'A Healthy Start' and 'PLAYgrounds'. In 'A Healthy Start', ECEC teachers learn to provide a healthy and active environment for toddlers. The 'PLAYgrounds for Toddlers' program, coaches ECEC teachers to stimulate physical activity in the playgrounds of preschools. PreSchool@HealthyWeight aims to evaluate the effectiveness of the intervention after 9 months. Primary outcomes are the teachers' knowledge, attitude and practices concerning healthy eating and physical activity, and consequently the level of confidence of ECEC teachers in promoting healthy eating and physical activity in toddlers. Secondary outcomes include the Body Mass Index, body composition, dietary intake and physical activity level of teachers and toddlers. In addition, the activating role of ECEC teachers and the physical activity of toddlers on the playgrounds will be evaluated. Lastly, the knowledge, attitude and practices of parents concerning healthy eating and physical activity will be assessed.

DISCUSSION

It is hypothesized that this preschool-based intervention for ECEC teachers improves the knowledge, attitude and practices regarding healthy eating and physical activity, and consequently the level of confidence of ECEC teachers in promoting healthy eating and physical activity of toddlers. The intervention addresses the call for early intervention to prevent overweight and obesity and to minimize health inequalities.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NL5850 . Date registered: August 26, 2016.

Screening and supporting through schools: educational experiences and needs of adolescents living with HIV in a South African cohort

BACKGROUND

Many adolescents living with HIV remain disconnected from care, especially in high-prevalence settings. Slow progressors-adolescents infected perinatally who survive without access to lifesaving treatment-remain unidentified and disconnected from heath systems, especially in high-prevalence settings. This study examines differences in educational outcomes for ALHIV, in order to i) identify educational markers for targeting HIV testing, counselling and linkages to care, and ii) to identify essential foci of educational support for ALHIV.

METHODS

Quantitative interviews with N = 1063 adolescents living with HIV and N = 456 HIV-free community control adolescents (10-19 year olds) included educational experiences (enrolment, fee-free school, school feeding schemes, absenteeism, achievement), physical health, cognitive difficulties, mental health challenges (depression, stigma, and trauma), missing school to attend clinic appointments, and socio-demographic characteristics. Voluntary informed consent was obtained from adolescents and caregivers (when adolescent < 18 years old). Analyses included multivariate logistic regressions, controlling for socio-demographic covariates, and structural equation modelling using STATA15.

RESULTS

ALHIV reported accessing educational services (enrolment, free schools, school feeding schemes) at the same rates as other adolescents (94, 30, and 92% respectively), suggesting that school is a valuable site for identification. Living with HIV was associated with poorer attendance (aOR = 1.7 95%CI1.1-2.6) and educational delay (aOR1.7 95%CI1.3-2.2). Adolescents who reported educational delay were more likely to be older, male, chronically sick and report more cognitive difficulties. A path model with excellent model fit (RMSEA = 0.027, CFI 0.984, TLI 0.952) indicated that living with HIV was associated with a series of poor physical, mental and cognitive health issues which led to worse educational experiences.

CONCLUSION

Schools may provide an important opportunity to identify unreached adolescents living with HIV and link them into care, focusing on adolescents with poor attendance, frequent sickness, low mood and slow learning. Key school-based markers for identifying unreached adolescents living with HIV may be low attendance, frequent sickness, low mood and slow learning. Improved linkages to care for adolescents living with HIV, in particular educational support services, are necessary to support scholastic achievement and long-term well-being, by helping them to cope with physical, emotional and cognitive difficulties.

The Daily Mile: teachers' perspectives of the barriers and facilitators to the delivery of a school-based physical activity intervention

OBJECTIVES

Children spend a significant amount of their time in a school environment, often engaged in sedentary activities. The Daily Mile is a physical activity intervention which aims to increase physical activity and fitness in children through the completion of an outdoor teacher-led walk or run during the school day. This study aimed to explore the barriers, facilitators and perceived benefits of the Daily Mile from the perspectives of teachers through the use of qualitative semi-structured interviews. It also aimed to identify important context-specific factors, which might require consideration for those who intend to adopt the Daily Mile.

SETTING

Eight Local Authority primary schools in the City of Edinburgh and East Lothian, UK.

PARTICIPANTS

Thirteen teachers (eleven women) who teach children in primaries one to seven in a school which delivered the Daily Mile.

RESULTS

Data were analysed using an interpretative thematic analysis. Teachers were positive and enthusiastic about the Daily Mile and perceived it to be beneficial to children's health and fitness. A number of barriers to participation were identified including inadequate all-weather running surfaces and time constraints in an already full school curriculum. The perceived impact on learning time was identified as a concern for teachers, while other benefits were also identified including increased teacher-child rapport and perceived enhanced classroom concentration levels.

CONCLUSION

The Daily Mile appears to be a valuable addition to the school day, however important context-specific barriers to delivery of the Daily Mile exist, which should be considered when implementing the Daily Mile in schools.

Context Considerations for Developing the In Defense of Food Nutrition Education Curriculum

OBJECTIVE

To examine perceptions of teachers and afterschool program staff related to the positive aspects and challenges of afterschool education for youth to guide the development of the "In Defense of Food" nutrition education curriculum.

METHODS

Semi-structured in-depth interviews with a convenience sample of teachers and afterschool program staff experienced serving at-risk youth were conducted in New York, NY. They were audio-recorded, transcribed verbatim, and analyzed using inductive summative content analysis to identify, count, and compare themes.

RESULTS

Interviews (n = 12) generated 2 meta-themes (Pedagogical Elements for Successful Learning and Pragmatic Considerations for hosting health promotion programs in the afterschool context). Learner-centered and tailored approaches and building social connection were considered important for fostering learning in the afterschool context.

CONCLUSIONS AND IMPLICATIONS

This study emphasizes the importance of considering pedagogical elements related to delivery that minimizes didactic instruction and focuses on learner-centered approaches. Further research is needed to compare outcomes and process measures common approaches used in designing nutrition education curricula with those that have been described in this study.

Integration of Onsite Long-Acting Reversible Contraception Services Into School-Based Health Centers

BACKGROUND

With recent recommendations from professional organizations, long-acting reversible contraception (LARC) methods are considered appropriate first-line contraception for adolescents. Many school-based health centers (SBHCs) in New York City (NYC) have recently added onsite LARC insertion and management to their contraceptive options. We aimed to explore key elements needed to implement LARC training and services into the SBHC setting and to identify successful factors for program implementation.

METHODS

Semistructured qualitative interviews were conducted with 19 providers and staff at 7 SBHCs in high schools in the Bronx and analyzed using Dedoose.

RESULTS

Support and leadership from administration; comprehensive onsite training of providers and staff; developing an effective staffing model for procedure sessions; and patient-centered contraceptive counseling were 4 key themes named by respondents as crucial to the program implementation process.

CONCLUSIONS

Integrating LARC services onsite at SBHCs is feasible and positively received by providers and staff. With good leadership, staffing, training, and appropriate contraceptive counseling, both SBHCs and other primary clinics that serve adolescents can integrate LARC insertion, removal, and management into routine contraceptive care. This in turn can increase youth access to these methods.

Association of Education Outside the Classroom and Pupils' Psychosocial Well-Being: Results From a School Year Implementation

BACKGROUND

Education Outside the Classroom (EOtC) is a teaching method that is gaining traction, aiming to promote learning and well-being. However, research on the association between EOtC and well-being is limited.

METHODS

This quasi-experimental trial involved pupils (9-13 years) from 16 Danish public schools which implemented EOtC in some classes. Pupils (N = 511) from 27 classes were regularly exposed to EOtC (2-7 hours per week), and pupils (N = 120) from 7 parallel comparison classes were much less exposed (less than 2 hours per week). The pupils' psychosocial well-being was measured at the beginning and end of the school year using the Strengths and Difficulties Questionnaire. The results were compared between the groups.

RESULTS

Pupils regularly exposed to EOtC showed the greatest improvement in prosocial behavior. Negative associations were seen between EOtC and hyperactivity-inattention and peer problems in pupils of low socioeconomic status (SES). The observed improvements were smaller when the EOtC was spread over a larger number of sessions. Results were independent of sex.

CONCLUSIONS

Regular exposure to EOtC was found to promote social well-being, especially for pupils of low SES, and was most beneficial when concentrated in fewer, longer sessions.

iAmHealthy: Rationale, design and application of a family-based mHealth pediatric obesity intervention for rural children

Children in rural areas are disproportionately affected by pediatric obesity. Poor access to healthcare providers, lack of nutrition education, lower socioeconomic status, and fewer opportunities to be physically active are all unique barriers that contribute to this growing health concern. There are very few pediatric obesity interventions that have been developed that target this unique population. iAmHealthy is a family-based behavioral, nutrition and physical activity intervention developed with input from rural children and families that capitalizes on the innovative use of mobile health applications (mHealth). iAmHealthy is a 25-contact hour multicomponent intervention delivered over an 8-month period targeting 2nd-4th grade school children and their families. This paper describes the rationale, design, participant/school enrollment, and planned implementation of a randomized controlled trial of the iAmHealthy intervention in comparison to a monthly newsletter delivered through rural elementary schools. Child Body Mass Index z-score (BMIz) is the primary outcome, along with child 24-hour dietary recall, and child accelerometer-determined physical activity and sedentary behavior as secondary outcomes. The study will include 18 schools (with 8 children each) resulting in a final planned sample size of 144 children. This project also has a strong focus on dissemination and implementation science, and thus includes many measures related to the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Data collection is completed at baseline, end of intervention (8 months), and follow-up (20 months). This study is the first randomized controlled trial to deliver a rurally tailored, empirically supported, family-based behavioral intervention for pediatric obesity solely over mHealth. Registered with ClinicalTrials.gov NCT ID 03304249.

A Participatory Process to Engage Appalachian Youth in Reducing Sugar-Sweetened Beverage Consumption

Children and adolescents consume excessive amounts of sugar-sweetened beverages (SSBs), which are associated with adverse health outcomes. We describe a yearlong participatory research study to reduce SSBs in Central Appalachia, where excessive consumption is particularly prevalent. This study was conducted in partnership with a community advisory board in Southwest Virginia. Nine "youth ambassadors," aged 10 to 13 years helped to systematically adapt SIPsmartER, an effective theory-based program for Appalachian adults, to be age and culturally appropriate and meet desired theoretical objectives. They then assisted with delivering the curriculum during a school-based feasibility study and led an advocacy event in their community. Satisfaction surveys and feedback sessions indicate that ambassadors found the program acceptable and important for other students. Validated surveys and focus groups suggested that theoretical objectives were met. Findings from these mixed methods sources informed curricular changes to further enhance acceptability and refine theoretical objectives. Participation in follow-up advocacy activities was tracked and described. Following the yearlong study, ambassadors reported having advocacy skills and motivation to continue reducing SSB intake in their community. Results, challenges, and lessons learned are presented to inform larger efforts to enhance acceptability of programs and inspire youth to take action to reduce health disparities in Appalachian communities.

Paediatric vision screening by non-healthcare volunteers: evidence based practices

BACKGROUND

The purpose of this study was to test the sensitivity and specificity of eight undergraduate volunteer examiners conducting vision screening tests in a community setting, in order to determine if non-eye care professionals were able to be trained to an appropriate level of skill.

METHODS

Eight undergraduate volunteer examiners were trained to conduct vision screening tests to address a gap in pediatric community eye care. Phase I of the study was implemented in the pediatric ophthalmology clinic, and phase II was conducted in nine local schools. Phase I consisted of 40 h of training for each volunteer regarding specific vision tests. Phase II consisted of screening children at nine local schools.

RESULTS

A total of 690 children from nine local schools were screened by both the volunteer examiners and the optometrist during the course of this study. Volunteer examiners had a screening sensitivity of 0.80 (95%CI 0.66-0.90) and screening specificity of 0.75 (95%CI 0.71-0.78) when compared to the study optometrist. The overall accuracy of volunteer examiners was 75%. The resulting positive likelihood ratio was 3.24 (95%CI 2.6-3.9), indicating that a child with vision impairment was 3.2 times more likely to fail the vision test performed by the volunteer examiners compared to a child with no vision impairment.

CONCLUSIONS

Non-healthcare professionals can be trained to an acceptable degree of accuracy to perform vision screening tests on children, which may assist in mitigating existing gaps in paediatric eye care.

Long-term effectiveness of a gambling intervention program among children in central Illinois

Youth gambling is an increasing concern. As a response, the “Don’t Gamble Away our Future (DGAOF)” program has been implemented among children in central Illinois. We aim to assess the long-term effectiveness of this school-based youth gambling prevention program in Illinois using the data from 2005 to 2009. The intervention included interactive PowerPoint presentations and prevention materials in parent packets. Students aged 8 to 18 years were eligible to participate in the intervention and the questionnaire pre-post knowledge tests (total score 0–9). Students in 5th grade and above also received a gambling behavior screen test using the Modified South Oaks Gambling Screening for Teens (MSOGST) for identifying probable gamblers. Multivariable generalized mixed models were conducted to detect the effects of a 5-year youth gambling prevention program as controlling potential confounders. A total of 16,262 and 16,421 students completed pre-post tests and MSOGST tests, respectively. Of 16,262, half were female, the majority (76.1%) were from senior high school, and 21.3% received the intervention at least twice. The median gap between interventions was 368 days. Students receiving multiple interventions had higher scores on the pre-test as compared to those receiving a single intervention (P<0.001 for all comparisons among groups), and they demonstrated an increasing trend of awareness about gambling over time (P<0.001 for multiple interventions; P = 0.538 for single intervention). The prevalence of problem gambling had decreased among students receiving the intervention twice as compared to receiving the intervention once (7.9% versus 9.4%; OR = 0.89, 95% CL: 0.82–0.97). However, this effect was not confirmed among students receiving the intervention three or more times. In conclusion, the DGAOF program has demonstrated a positive long-term impact on increasing gambling knowledge and partially reducing pathological gamblers through direct training. It suggests that multiple repeated interventions are important for youth gambling prevention.

A review of the sustainability and impact of a healthy lifestyles programme in primary schools 2-5 years after the intervention phase

There has been an emphasis on schools to promote healthy lifestyles and many intervention programmes have attempted this. Most programmes are evaluated at the time and/or shortly afterwards. This is a review of the impact and sustainability of the Health for Life programme 2-5 years after the initial phase. It captures the experiences of the senior school staff who delivered the programme through semi-structured interviews. Senior teachers recognized the importance of promoting healthy lifestyles in primary schools. They reported positively on aspects of the programme, in particular its flexibility and how it enabled schools to develop a new relationship with parents and how schools have sustained the initial programme. They discussed the main barriers to intervention and how they could be mitigated. Delivering a sustainable healthy lifestyle primary schools programme which has an impact is feasible but challenging for school staff. To maximize the likelihood of delivery, interventions must be championed by a member of the Senior Leadership Team, embedded in the curriculum, hands-on, easy to manage, and flexible to the needs of individual schools but requires support (financial, training and advisory). With these conditions the sustainability and impact of the programme was significant.

Barriers to Human Sexuality Education Survey Research Among Vermont Public School Administrators

BACKGROUND

Health educators in public high schools can provide educational interventions to reduce teen unintended pregnancy and sexually transmitted infections (STIs). Characteristics of teachers and schools influence their decision to provide condom education. Studies to determine characteristics must be conducted so HIV/sex education can be improved. If schools do not participate in these studies, barriers must be identified so researchers can collect sufficient data to produce information for curriculum reform.

METHODS

A study was conducted to identify teacher characteristics that influence their decision and intention to provide appropriate condom education. Follow-up e-mails were sent to administrators who opted out of the study to request more information about their decision to not participate. All responses were submitted via e-mail correspondence.

RESULTS

Six superintendents and 6 principals provided a reason for their decision to opt out. Superintendents cited being busy with district initiatives, time constraints, and lack of interest in participating in the study as reasons they did not wish to participate. Principals cited competing requests for participation in research, participation in other surveys, and time constraints.

CONCLUSIONS

Securing administrative approval for human sexuality research is challenging. Administrators contend with many priorities, do not wish to overburden teachers, consider participation in voluntary research as a low priority, and may be more likely to respond to telephone requests. Administrators may not want to disclose that human sexuality or HIV education courses may not be taught by certified or qualified health educators.

Working on Womanhood (WOW): A participatory formative evaluation of a community-developed intervention

The well-documented disparities in availability, accessibility, and quality of behavioral health services suggest the need for innovative programs to address the needs of ethnic minority youth. The current study aimed to conduct a participatory, formative evaluation of "Working on Womanhood" (WOW), a community-developed, multifaceted, school-based intervention serving primarily ethnic minority girls living in underserved urban communities. Specifically, the current study aimed to examine the feasibility, acceptability, and initial promise of WOW using community-based participatory research (CBPR) and represented the third phase of a community-academic partnership. Qualitative and quantitative data were collected from 960 WOW participants in 21 urban public schools, as well as WOW counselors, parents, and school staff over the course of one academic year. Results demonstrated evidence of acceptability of WOW and noteworthy improvements for WOW participants in targeted outcomes, including mental health, emotion regulation, and academic engagement. Findings also indicated several challenges to implementation feasibility and acceptability, including screening and enrollment processes and curriculum length. Additionally, we discuss how, consistent with participatory and formative research, findings were used by program implementers to inform program improvements, including modifications to screening processes, timelines, curriculum, and trainings - all in preparation for a rigorous effectiveness evaluation.

Self-Reported Engagement in a Drug Prevention Program: Individual and Classroom Effects on Proximal and Behavioral Outcomes

Numerous studies emphasize the role of student engagement in academic learning and performance. Less known is whether engagement plays a role in drug prevention program outcomes. We examined a self-report measure of engagement as part of the All Stars Core drug prevention program evaluation, assessing its impact on target risk mechanisms and behavioral outcomes. Students completed pretests just prior to and posttests just after completing the intervention. Surveys assessed demographics, proximal intervening measures (i.e., commitments to avoid substance use and antisocial behavior, perceived lifestyle incongruence with substance use and antisocial behavior, normative beliefs about substance use and antisocial behavior, and parental attentiveness), and distal outcome measures of alcohol, cigarette use, and antisocial behaviors. A brief 6-item posttest measure including items tapping the students' perspective on the quality of teaching the program material and their level of engagement with the program was internally consistent (α = .79). Multi-level analyses positing engagement effects at both the classroom- and individual-level indicated that classroom average engagement was significantly associated with all the targeted risk mechanisms, and outcomes of antisocial behavior and alcohol use, controlling for pretest measures and classroom size. Individual student engagement relative to classroom peers was significantly associated with all posttest target risk mechanisms and behavioral outcomes. The current findings suggest that students should routinely provide assessments of engagement and perceived quality of teaching, which would improve our understanding of how prevention programs work. Teachers can improve engagement by paying attention to students when they speak in class, making the program enjoyable to participants, encouraging students to share opinions, stimulating attentiveness, being well prepared to deliver the intervention, and helping students think broadly about implications of drug prevention as it affects their lives. This type of support will ultimately engage students in ways that will enhance the likelihood that these programs will have their desired effects.

Design and methodology of a cluster-randomized trial in early care and education centers to meet physical activity guidelines: Sustainability via Active Garden Education (SAGE)

Strategies are needed to help early care and education centers (ECEC) comply with policies to meet daily physical activity and fruit and vegetable guidelines for young children. This manuscript describes the design and methodology of Sustainability via Active Garden Education (SAGE), a 12-session cluster-randomized controlled crossover design trial using community-based participatory research (CBPR) to test a garden-based ECEC physical activity and fruit and vegetables promotion intervention for young children aged 3-5 years in 20 sites. The SAGE curriculum uses the plant lifecycle as a metaphor for human development. Children learn how to plant, water, weed, harvest, and do simple food preparation involving washing, cleaning, and sampling fruit and vegetables along with active learning songs, games, science experiments, mindful eating exercises, and interactive discussions to reinforce various healthy lifestyle topics. Parents will receive newsletters and text messages linked to the curriculum, describing local resources and events, and to remind them about activities and assessments. Children will be measured on physical activity, height, and weight and observed during meal and snack times to document dietary habits. Parents will complete measures about dietary habits outside of the ECEC, parenting practices, home physical activity resources, and home fruit and vegetable availability. SAGE fills an important void in the policy literature by employing a participatory strategy to produce a carefully crafted and engaging curriculum with the goal of meeting health policy guidelines and educational accreditation standards. If successful, SAGE may inform and inspire widespread dissemination and implementation to reduce health disparities and improve health equity.

An evaluation of stakeholder capacity in the implementation of millenium village primary school meal project

The paper focused on evaluation of stakeholder capacity to implement the millennium village primary school meal project in Kenya. The study which was anchored on the stakeholder theory as well as the Context Input Process Product (CIPP) model of evaluation used mixed methods research design with ex-post facto and case study as its two research elements. The mixed methods was adopted because when both qualitative and quantitative approaches are used in a single study, the strengths of both produce a research synergy in which the collective benefits are greater than what is obtained from either approach when used alone. A sample size of 186 participants was selected from seven (7) primary schools using stratified random sampling. The participants selected purposively included pupils, teachers, head teachers, parents, Area Education Officer (AEO) and project staff. Data was collected using questionnaires, face to face interview guide, Focus Group Discussion (FGD) and document analysis guide. The study findings indicated that the project was implemented with great success as indicated by stakeholders' capacity to understand project objectives, their involvement in project planning and implementation and their positive attitude towards the project. This has contribute to poverty reduction in the community through the project and sustainable approaches for project implementation.

Evaluation of Together We Inspire Smart Eating: pre-school fruit and vegetable consumption

This study examined nutrition intervention curriculum, Together We Inspire Smart Eating (WISE). WISE is a research-based, nutrition promotion curriculum specifically designed for pre-school children from families with limited resources. The design was non-randomized treatment/control with standardized pre-/post-test assessments. Children (n = 268) in six Head Start centers received weekly food experiences from educators trained in WISE. Children (n = 258) in nine Head Start centers received weekly food experiences structured at the discretion of the educators untrained in WISE. Parents in both conditions (n = 268 WISE classroom, n = 258 comparison) were interviewed by educators twice over the school year using a data collection tool, The Family Map Inventory. Analyses using full information maximum likelihood controlling for pre-intervention consumption and key demographic characteristics was used to predict consumption at post-intervention assessment. Results indicated children in WISE centers consumed healthier food at home than children in non-WISE classrooms. The study suggested that WISE curriculum is an effective method to improve children's diets in at-risk environments.

Implementation fidelity and adolescent smoking: The X:IT study-A school randomized smoking prevention trial

BACKGROUND

Assessing the actual implementation of multi-component interventions can provide important knowledge for future interventions. Intervention components may be implemented differently, knowledge about this can provide an understanding of which components are essential and therefore must be included. The aim of this study was to examine the implementation of one, two, or all three main intervention components at the individual level and to assess the association to current smoking among 13 year-olds in the X:IT study.

METHODS

Data stems from a cluster-randomized controlled trial in 94 Danish elementary schools (51 intervention; 43 control schools). Implementation was measured by aspects of adherence, dose, quality of delivery, and participant responsiveness based on questionnaire data from 4161 pupils at baseline (mean-age: 12.5 years) and 3764 pupils at first follow-up eight months later. Coordinator responses from 49 intervention schools were also included. Associations between individual level implementation of the three main components and pupil smoking were examined through a 3-level logistic regression model.

RESULTS

Although implementation fidelity for the three main intervention components was good, only one third (38.8%) of pupils in intervention schools were exposed to full implementation of the intervention. Among these pupils odds ratio for smoking was 0.25 (95% CI: 0.15 - 0.42).

CONCLUSIONS

School-based programs can be very effective if carefully implemented. Future school-based smoking preventive initiatives should include multiple components, and seek to enhance implementation quality of all components.

Case study of a health optimizing physical education-based comprehensive school physical activity program

In this article, we report a qualitative case study, in which we examined enablers and barriers related to the development, implementation, and sustainability of a comprehensive school physical activity program (CSPAP) aligned with the Health Optimizing Physical Education (HOPE) curriculum model at a middle school. Literature on program-diffusion and school-university partnerships guided data collection and analysis. Data sources included semi-structured interviews with the program implementation team (n = 9) and the school's health and physical education teachers (n = 7); a focus group interview with students; documents (e.g., lesson plans), and observations. Constant comparison techniques were used to code and draw out themes from the data. Findings revealed the extensive effort needed for program implementation and highlighted the importance of strong external support mechanisms, conducting needs assessments, and training teachers to market physical activity programming. Partnerships may provide critical support for schools in their efforts to generate and sustain CSPAPs.

Enhancing Parent Consent for School-Based Primary and Reproductive Health Care Among Vulnerable Youth

This quality-improvement initiative evaluated procedures to increase parental consent for students, 13 to 18+ years old, to access a school-based health clinic that provides primary and reproductive health care in a Hispanic immigrant neighborhood in the U.S. Southwest. Six consent-retrieval procedures were sequentially implemented. Procedures included school registration, competition, hand delivery, PTO meetings, self-consent, and mail. Age, grade, and number of completed consents were calculated and compared. The percentage of students with completed consents increased from 35% to 72%. Lessons learned include increasing the number of completed consents is difficult; however, it is important to increase students' access to health-care services.

Prevalence and Types of School-Based Out-of-School Time Programs at Elementary Schools and Implications for Student Nutrition and Physical Activity

BACKGROUND

Out-of-school time (OST) programs are an important setting for supporting student health and academic achievement. This study describes the prevalence and characteristics of school-based OST programs, which can inform efforts to promote healthy behaviors in this setting.

METHODS

A nationally representative sample of public elementary schools (N = 640) completed surveys in 2013-2014. Administrators reported on OST programs and policies at their school. Multivariable logistic regression models estimated the prevalence of school-based OST programs, adjusting for school characteristics. Among schools with OST programs (N = 475), chi-square tests identified school characteristics associated with having an OST policy about physical activity or nutrition.

RESULTS

Three fourths of elementary schools (75.6%) had a full- or partial-year school-based OST program, with 30.8% having both. Full- and partial-year programs were significantly less prevalent in rural and township areas versus urban settings. Only 27.5% of schools with OST programs reported having physical activity and/or nutrition policies.

CONCLUSIONS

Most US elementary schools have an on-site OST program, but disparities in access exist, and most lack policies or awareness of existing policies regarding physical activity and nutrition. To maximize OST programs' potential benefits, strategies are needed to increase access to programs and physical activity and/or nutrition policy adoption.