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

The Impact of Implementation Fidelity of a School-Based Multi-Component Smoking Prevention Intervention on Vocational Students' Smoking Behavior: A Cluster-Randomized Controlled Trial

Preventing young people's cigarette smoking is a major public health priority, and smoking is especially prevalent in vocational schools. Well-enforced comprehensive school tobacco policies accompanied by preventive efforts show potential to reduce smoking, but the implementation process is crucial to achieve the intended effect. We investigate whether and how implementation fidelity of a multi-component smoking prevention intervention impacted student smoking outcomes after 4-5 months among students in Danish vocational education and training (national age range 15-65 years, mean 25.6) and preparatory basic education (national age range 15-25 years, mean 17.6) institutions using questionnaire data from a cluster-RCT. The intervention included a smoke-free school hours policy, educational curriculum, and class competition. We calculated an overall implementation fidelity measure combining staff-reported school-level delivery (fidelity) and student-reported receipt (participation, responsiveness), and used multilevel regression models to analyze associations with smoking outcomes (smoking daily, regularly, and during school hours). We supplemented the analysis with restricted cubic spline regression. Additionally, we stratified the analyses by school types and analyzed associations between implementation fidelity of the separate intervention components and smoking outcomes. High implementation was associated with lower odds of regular smoking (OR: 0.37, 95% CI: 0.18-0.78) and smoking during school hours, but not daily smoking, and these associations varied between the school settings. When analyzed separately, implementation fidelity of the components did not affect the outcomes significantly. Our findings underline the need to support the implementation process of school tobacco policy interventions to ensure the intended effects of reducing students' smoking.

Socioeconomic Differences in Cigarette Smoking and Alternative Tobacco Product Use Among Adolescents in a School-Based Smoking Preventive Intervention: Findings From the Second Year of the X:IT II Study

Background

Health interventions may differently impact adolescents from diverse backgrounds. This study examined whether a smoking preventive intervention was equally effective in preventing cigarette smoking and use of alternative tobacco products (ATPs, i.e., snus, e-cigarettes, and waterpipe) among students from different socioeconomic backgrounds, i.e., occupational social classes (OSC).

Methods

Data was from the school-based intervention X:IT II targeting 13- to 15-year-olds Danes. The intervention focused on three main components: smoke-free school time, smoke-free curriculum, and parental involvement. In total, 46 schools were included at baseline (N = 2,307, response rate = 86.3%). Using a difference-in-differences approach, changes in current smoking and ever use of ATPs were estimated among students in high versus low OSC at second follow-up. Analyses were based on available cases (N = 826) and multiple imputations of missing data at the second follow-up (N = 1,965).

Results

At baseline (age 13), 1.0% of students from high OSC and 4.8% from low OSC currently smoked cigarettes, while this was the case among 24.5 and 25.6%, respectively, at the second follow-up (age 15). Estimates indicated that social inequalities in current smoking diminished over time (p < 0.001). Regarding ATPs, 10.0% of high OSC students and 13.9% of low OSC students had ever used ATPs at baseline, while at second follow-up, 46.8 and 60.8%, respectively, had ever used ATPs. Estimates indicated that social inequalities in ever use of ATPs widened over time (p < 0.001).

Conclusions

The X:IT II intervention seemed to diminish socioeconomic disparities in smoking over the study period. Meanwhile, social inequalities in ever use of ATPs increased. Therefore, besides focusing on narrowing the social disparities in cigarette smoking, future efforts may, to a larger extent, focus on adolescents' use of ATPs.

Study Protocol for Evaluation of an Extended Maintenance Intervention on Life Satisfaction and BMI Among 7-14-Year-Old Children Following a Stay at a Residential Health Camp in Denmark

Background: It is challenging to maintain effects of public health interventions. For residential health camps benefits often disappear as the child returns home. Furthermore, long-term effects are often not measured or reported. This paper presents the study protocol for an evaluation of an extended maintenance intervention offered to children who have completed a 10-week residential health camp at one of the five Danish Christmas Seal Houses (DCSH). The target group of DSCH is 7–14-year-olds with social, mental, and/or overweight issues and the overall aim of the camp is to increase life satisfaction and a healthy lifestyle. The primary aim of this study is to assess the effectiveness of the maintenance intervention on children's life satisfaction (primary outcome) and BMI Z-score (secondary outcome) 1 year after health camp.

Methods: The extended maintenance intervention is developed by DCSH and delivered to each child and family individually by an intervention coordinator to help children maintain positive benefits of the health camp on life satisfaction and health behaviors after returning to their homes. Intervention activities target the child and the family. The effect will be tested in a quasi-experimental design: The intervention is offered to half of the children at one of the five DSCH (intervention group, N~144) while the other half and the children at the other four DSCH receive a standard maintenance intervention (control group, N~894). Children will complete questionnaires on life satisfaction measured by an adapted version of the Cantril ladder and height and weight prior to health camp, at the end of health camp, 3 months and 1 year after the end of health camp. To enable per protocol analysis and nuanced interpretation of effect estimates, we will monitor the implementation of the intervention by a process evaluation study among children, parents, and follow up coordinators using qualitative and quantitative methods.

Discussion: We present a systematic approach to evaluating practice-based interventions in a research design. The study will provide new knowledge on the effectiveness of individualized maintenance interventions on long-term effects on life satisfaction and weight loss among children.

Trial registration: Prospectively registered at Current Controlled Trials ISRCTN 13011465 https://www.isrctn.com/ISRCTN13011465

Identifying the "Active Ingredients" of a School-Based, Workplace Safety and Health Training Intervention

Young workers in many industrialized countries experience a higher rate of largely preventable occupation-related injuries compared with adults. Safety education and training are considered critical to the prevention of these incidents. This can be promoted by the dissemination and scale-out of an evidence-based, safety training programs in vocational education. The aim of this study was to identify the intervention core components that comprise the "active ingredients" of a safety training intervention for young workers and assess the impact on student outcomes of interest. Fidelity of implementation was operationalized using measures of adherence and quality of intervention delivery. For this study, data were collected through a school-based, cluster randomized trial conducted in 2015 in eight Finnish upper secondary-level vocational schools (n = 229 students in 22 groups, each with one teacher). Results indicate that the intervention core components (safety skills training, safety inoculation training, a positive atmosphere for safety learning, and active learning techniques) had differing associations with student outcomes. Adherence related to the acquisition of safety skills training was the strongest active ingredient in terms of positive effects. Furthermore, quality of delivery in terms of fostering positive learning atmosphere and utilizing active learning methods was associated especially with motivational outcomes. These findings indicate that different active ingredients complemented each other. Contrary to expectations, we found no statistically significant relationship between any of the core components and risk-taking attitudes. The current study advances prevention science by identifying the active ingredients of an evidence-based intervention, implemented in Finnish vocational school settings, that helps protect young workers from work-related morbidity and mortality.

Predictors of High Program Exposure Among Adolescents Participating in a Smoking Prevention Intervention in Romania

Introduction:

Web-based smoking prevention programs can be delivered to large groups of adolescents under relatively private conditions at a convenient cost, but their effectiveness is highly dependent on the level of exposure to the educational content. The objective of the study was to identify the predictors of high program exposure among a group of adolescents participating in a web-based smoking prevention cluster randomized trial in Romania.

Methods:

The study sample included 675 adolescents from Târgu Mureş, Romania. The level of exposure to the ASPIRE web-based smoking prevention program was monitored using data automatically saved on the system server. High program exposure was defined as watching 75% to 100% of the educational content. Associations between adolescents’ sociodemographic, psychological, and behavioral variables collected online at the beginning of the intervention and high program exposure were tested using chi-square test and logistic regression.

Results:

In all, 68.3% of students were highly exposed to the program. There were 4 significant predictors of high program exposure in the multivariable logistic regression model: participant’s father’s lower level of education (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.19-2.44), participant’s brother’s nonsmoking status (OR: 1.76; 95% CI: 1.13-2.72), never trying e-cigarettes (OR: 1.73; 95% CI: 1.22-2.45), and considering the health of others an important reason not to smoke (OR: 2.46; 95% CI: 1.54-3.93).

Conclusions:

The analysis identified sociodemographic, psychological, and behavioral factors that may be useful in project management of such intervention to improve program effectiveness.

Study protocol of the X:IT II - a school-based smoking preventive intervention

BACKGROUND

The X:IT intervention, conducted in 2010 to 2013, showed overall smoking preventive effect. However, parts of the intervention appeared less appealing to children from families with lower socioeconomic backgrounds. Therefore, the intervention components were modified and an evaluation of the amended intervention X:IT II is needed to show the effect of this revised intervention and whether children from different social backgrounds benefits equally from the current intervention.

METHODS

Main intervention components are smoke free schools, a curricular component, and parental involvement (smoke free agreements and talks about tobacco). Components have been revised from the first version; 1) previously, schools should be smoke free on the school ground and were encouraged to hide smoking so that it wasn't visible to pupils from the school ground. Now they are encouraged to tighten the rules so that no pupils or teachers smoke during the school day, no matter where they are; 2) the specifically developed educational material (Up in Smoke) has been revised so that all materials are online and all texts has a ARI; 3) the parental involvement is now targeted multiple groups of parents, e.g. parents that are smokers, and parents of children that smoke. Language used is simpler and the website for parents presents very specific examples. X:IT is implemented in 46 Danish public schools from fall 2017 until summer 2020. Data is collected through electronic questionnaires to students and coordinators four times (fall 2017, spring/summer 2018, 2019 and 2020). Further, qualitative interviews and observations are conducted.

DISCUSSION

Prevalence of smoking among Danish adolescents is high compared to other Nordic countries and there is social inequality in smoking, leaving individuals from the lowest social backgrounds at higher risk. Although there has been an overall decline in smoking among Danish adolescents over the last decades, a recent levelling of this development indicates an urgent need for smoking prevention in Denmark. The X:IT intervention has the potential to prevent uptake of smoking among adolescents. However, there is a particular need for evaluating the effectiveness of the revised X:IT intervention, X:IT II, with focus on the effect across socioeconomic groups of adolescents.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN31292019 , date of registration 24/10/2017. Retrospectively registered.