Effects of the Positive Action programme on problem behaviours in elementary school students: a matched-pair randomised control trial in Chicago

Violence outcomes in later adolescence with the Good School Toolkit-Primary: a nonrandomized controlled trial in Uganda

BACKGROUND

We sought to determine whether the Good School Toolkit-Primary violence prevention intervention was associated with reduced victimisation and perpetration of peer and intimate partner violence four years later, and if any associations were moderated by sex and early adolescent: family connectedness, socio-economic status, and experience of violence outside of school.

METHODS

Drawing on schools involved in a randomised controlled trial of the intervention, we used a quasi-experimental design to compare violence outcomes between those who received the intervention during our trial (n = 1388), and those who did not receive the intervention during or after the trial (n = 522). Data were collected in 2014 (mean age 13.4, SD 1.5 years) from participants in 42 schools in Luwero District, Uganda, and 2018/19 from the same participants both in and out of school (mean age 18, SD: 1.77 years). We compared children who received the Good School Toolkit-Primary, a whole school violence prevention intervention, during a randomised controlled trial, to those who did not receive the intervention during or after the trial. Outcomes were measured using items adapted from the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. We used mixed-effect multivariable logistic regression, with school fitted as a random-effect to account for clustering.

RESULTS

1910 adolescents aged about 16-19 years old were included in our analysis. We found no evidence of an average long-term intervention effect on our primary outcome, peer violence victimization at follow-up (aOR = 0.81, 95%CI = 0.59-1.11); or for any secondary outcome. However, exposure to the intervention was associated with: later reductions in peer violence, for adolescents with high family connectedness (aOR = 0.70, 95% CI 0.49 to 0.99), but not for those with low family connectedness (aOR = 1.07, 95% CI 0.69 to 1.6; p-interaction = 0.06); and reduced later intimate partner violence perpetration among males with high socio-economic status (aOR = 0.32, 95%CI 0.11 to 0.90), but not low socio-economic status (aOR = 1.01 95%CI 0.37 to 2.76, p-interaction = 0.05).

CONCLUSIONS

Young adolescents in connected families and with higher socio-economic status may be better equipped to transfer violence prevention skills from primary school to new relationships as they get older.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01678846, registration date 24 August 2012. Protocol for this paper:  https://www.researchprotocols.org/2020/12/e20940 .

Antibullying Interventions in Schools: Assessing the Evidence Base

OBJECTIVE

This systematic review used established rating criteria to describe the level of evidence for interventions aimed at preventing or reducing bullying perpetration and victimization in schools, synthesized the evidence for students from racially and ethnically diverse backgrounds, and reviewed the literature for available information to conduct an economic analysis of the interventions.

METHODS

Major databases, gray literature, and evidence-base registries were searched to identify studies published from 2008 through 2022. The authors rated antibullying intervention models as having high, moderate, or low evidence depending on the number and rigor of studies with positive findings.

RESULTS

Overall, 80 articles reporting on 71 original research studies describing a total of 48 antibullying interventions met the inclusion criteria for this review. Two schoolwide interventions received a high-evidence rating: the KiVa (Kiusaamista Vastaan) Antibullying Program and the Friendly Schools program. Multilevel interventions with components at the levels of school, classroom, and individual student most consistently showed strong evidence for reducing bullying behavior in elementary and middle school grades. Four interventions yielded positive effects in reducing bullying and victimization among diverse samples of students.

CONCLUSIONS

Antibullying interventions can reduce bullying in schools. Some interventions show effectiveness with students from racially and ethnically diverse backgrounds. The gains relative to per-student costs were in the range that is considered cost-effective. Most implementation costs are spent on staff training and support. Research on successful implementation of whole-school interventions and additional synthesis of evidence pertaining to program structures would further advance the antibullying evidence base.

Whole-school interventions promoting student commitment to school to prevent substance use and violence, and improve educational attainment: a systematic review

Background

Whole-school interventions modify the school environment to promote health. A subset of these interventions promotes student commitment to school to prevent substance (tobacco, alcohol, other drugs) use and/or violence. A previous review identified the theory of human functioning and school organisation as a comprehensive theory of such interventions, and found evidence that these interventions reduce substance use and/or violence.

Objectives

The objectives were to search for, appraise and synthesise evidence to address the following questions: (1) What whole-school interventions promoting student commitment to school to prevent substance use and/or violence have been evaluated, what intervention subtypes are apparent and how closely do these align with the theory of human functioning and school organisation? (2) What factors relating to setting, population and intervention affect implementation? (3) What are the effects on student substance use, violence and educational attainment? (4) What is the cost-effectiveness of such interventions? (5) Are intervention effects mediated by student commitment to school or moderated by setting or population?

Data sources

A total of 56 information sources were searched (in January 2020), then an updated search of 48 of these was carried out (in May 2021). Reference lists were also searched and experts were contacted.

Review methods

Eligible studies were process/outcome evaluations of whole-school interventions to reduce student violence or substance use among students aged 5-18 years attending schools, via actions aligning with the theory of human functioning and school organisation: modifying teaching to increase engagement, enhancing student-staff relationships, revising school policies, encouraging volunteering or increasing parental involvement. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised qualitatively. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Searches retrieved 63 eligible reports on 27 studies of 22 interventions. We identified four intervention subtypes focused on student participation in school-wide decisions, improving staff-student relationships, increasing engagement in learning and involving parents. The theories of change of most intervention subtypes aligned closely with the theory of human functioning and school organisation, and informed refinement of an intervention theory of change. Theories of change for interventions increasing learning engagement did not align with this theory, aiming instead to increase school commitment primarily via social skills curricula. Factors influencing the implementation included whether or not interventions were tailorable, workable and well explained. Interventions with action groups comprising staff/students, etc. and providing local data were well implemented. Implementation was also affected by whether or not schools accepted the need for change and staff had the resources for delivery. Meta-analyses suggest small, but significant, intervention effects in preventing violence victimisation and perpetration, and substance use. There was sparse and inconsistent evidence of moderation and some evidence of mediation by student commitment to school. Two economic evaluations suggested that there is the potential for the interventions to be cost-effective.

Limitations

The quality of the studies was variable and the economic synthesis was limited to two studies.

Conclusions

Whole-school interventions aiming to promote student commitment to school share similar theories of change and factors affecting implementation. They have the potential to contribute to preventing violence and substance use among young people. Future trials should aim to optimise intervention effectiveness by better theorisation, and assess implementation and effect moderators and mediators.

Study registration

This study is registered as PROSPERO CRD42019154334.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/151/05) and is published in full in Public Health Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Whole-school interventions promoting student commitment to school to prevent substance use and violence: a systematic review

OBJECTIVES

Whole-school interventions that promote student commitment to school are a promising modality to reduce health inequalities through school-level change; however, evidence for the effectiveness of these interventions in improving policy-relevant health outcomes, such as substance use and violence, has not been comprehensively synthesised.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

We searched 20 databases and a range of other sources to identify randomised trials meeting our intervention definition and reporting substance use and violence outcomes. Extracted effect estimates were meta-analysed using robust variance estimation with random effects, separating effects <1 year from baseline and effects at or more than 1 year from baseline.

RESULTS

We included 18 evaluations with varying risk of bias. Pooled effects suggested significant impacts on short-term (odds ratio [OR] = 0.85, 95% confidence interval [CI] 0.76, 0.96) and long-term (OR = 0.79, 95% CI 0.65, 0.98) violence perpetration, short-term (OR = 0.84, 95% CI 0.72, 0.98) and long-term (OR = 0.85, 95% CI 0.73, 0.99) violence victimisation, and short-term (OR = 0.83, 95% CI 0.70, 0.97) and long-term (OR = 0.79, 95% CI 0.62, 0.998) substance use outcomes, with effects relatively stable between short-term and long-term analyses. Stratifying substance use meta-analyses by type (e.g. smoking, alcohol) did not impact results. All meta-analyses had substantial heterogeneity.

CONCLUSION

Although diverse in content, interventions appear effective with respect to the review outcomes and as a form of universal prevention. Future research should consider contextual contingencies in intervention effectiveness, given considerable policy and practice interest in these interventions and the need to support schools in effective decision-making as to intervention choice.

The Campbell Collaboration's systematic review of school-based anti-bullying interventions does not meet mandatory methodological standards

BACKGROUND

Many published reviews do not meet the widely accepted PRISMA standards for systematic reviews and meta-analysis. Campbell Collaboration and Cochrane reviews are expected to meet even more rigorous standards, but their adherence to these standards is uneven. For example, a newly updated Campbell systematic review of school-based anti-bullying interventions does not appear to meet many of the Campbell Collaboration's mandatory methodological standards.

ISSUES

In this commentary, we document methodological problems in the Campbell Collaboration's new school-based anti-bullying interventions review, including (1) unexplained deviations from the protocol; (2) inadequate documentation of search strategies; (3) inconsistent reports on the number of included studies; (4) undocumented risk of bias ratings; (5) assessments of selective outcome reporting bias that are not transparent, not replicable, and appear to systematically underestimate risk of bias; (6) unreliable assessments of risk of publication bias; (7) use of a composite scale that conflates distinct risks of bias; and (8) failure to consider issues related to the strength of the evidence and risks of bias in interpreting results and drawing conclusions. Readers who are unaware of these problems may place more confidence in this review than is warranted. Campbell Collaboration editors declined to publish our comments and declined to issue a public statement of concern about this review.

CONCLUSIONS

Systematic reviews are expected to use transparent methods and follow relevant methodological standards. Readers should be concerned when these expectations are not met, because transparency and rigor enhance the trustworthiness of results and conclusions. In the tradition of Donald T. Campbell, there is need for more public debate about the methods and conclusions of systematic reviews, and greater clarity regarding applications of (and adherence to) published standards for systematic reviews.

Effects of a School-Based Drug Prevention Program on Sexual Risk Behavior Among Adolescents in Brazilian Schools

Sexual risk behaviors are closely related to the use of alcohol, tobacco, and other illicit drugs as well as teen dating violence. School-based drug prevention programs that teach social and personal skills could potentially also reduce sexual risk behaviors. We examined the effects of the #Tamojunto program on youth sexual risk behaviors. A randomized controlled trial was conducted with 6391 7th and 8th grade students in 72 public schools in six Brazilian cities. Baseline data were collected prior to program implementation. Two waves of follow-up assessments occurred after 9 and 21 months. Analyses were performed taking into account the multilevel structure of the data. We used intention-to-treat to evaluate changes in the prevalence of sexual risk behaviors over time and between groups. Adolescent age ranged from 11 to 15 years, with a mean of 12.6 ± 0.8 years, and 51.0% were female. Among all participants, receipt of #Tamojunto was associated with higher risk of lifetime sex at 21 months follow-up (OR 1.27, 95% CI [1.03, 1.56]). Among girls, at 9 months follow-up, the program was associated with higher likelihood of having engaged in sex in the last month (OR 1.76, 95% CI [1.13, 2.74]). At 21 months follow-up, girls receiving the program were more likely to report engaging in condomless sex in the last month (OR 1.64, 95% CI [1.07, 2.50]). #Tamojunto may be ineffective and possibly harmful for preventing sexual risk behaviors, especially among girls. We suggest further investigation of the possible mediating role of life skills intervention components on girl's sexual behaviors.

When Does Rejection Trigger Aggression? A Test of the Multimotive Model

Research has sought to identify the conditions under which rejection leads to retaliation. The Multimotive Model (MMM) proposes that there are three primary behavioral responses to rejection: prosocial (e.g., befriending others), asocial (e.g., withdrawal), and antisocial behavior (e.g., aggression toward others). In this study, we conducted the first full test of the MMM as well as expanded the model. Based on research linking aggression and “perceived groupness,” construal items were added assessing whether the rejection was perceived as extending beyond the individual to one's peers. We also included self-harm behavioral responses as this outcome was not sufficiently captured by existing antisocial or asocial operationalizations. This expanded model was then tested with two high school student samples (Ns of 231 and 374) who reported experiencing aggressive rejection (i.e., experienced physical, verbal, relational, or cyber aggression from peers). The MMM was compared to a saturated model separately in each of the two datasets using structural equation modeling. Results indicate that the saturated model provides a better fit for the data than the MMM across all models examined (all p < 0.001). In part, this is due to certain paths having different associations than hypothesized. For example, perceiving the rejection as carrying a higher cost was predicted to promote prosocial behavior, where instead it predicted asocial responses. Perceived groupness was the strongest predictor of antisocial responses. Self-harm outcomes were significantly and consistently associated with higher perceived costs across the models. These results and others will be discussed in the context of how we can better encourage prosocial and discourage antisocial and self-harm responses to social rejection, including bullying.

Effectiveness of school-based programs to reduce bullying perpetration and victimization: An updated systematic review and meta-analysis

Background

Bullying first emerged as an important topic of research in the 1980s in Norway (Olweus), and a recent meta-analysis shows that these forms of aggression remain prevalent among young people globally (Modecki et al.). Prominent researchers in the field have defined bullying as any aggressive behavior that incorporates three key elements, namely: (1) an intention to harm, (2) repetitive in nature, and (3) a clear power imbalance between perpetrator and victim (Centers for Disease Control and Prevention; Farrington). There are many negative outcomes associated with bullying perpetration, such as: suicidal ideation (Holt et al.), weapon carrying (Valdebenito et al.), drug use (Ttofi et al.), and violence and offending in later life (Ttofi et al.). Bullying victimization too is associated with negative outcomes such as: suicidal ideation (Holt et al.), anxiety, low self-esteem and loneliness (Hawker& Boulton). Therefore, school bullying is an important target for effective intervention, and should be considered a matter of public health concern.

Objectives

The objective of this review is to establish whether or not existing school-based antibullying programs are effective in reducing school-bullyng behaviors. This report also updates a previous meta-analysis conducted by Farrington and Ttofi. This earlier review found that antibullying programs are effective in reducing bullying perpetration and victimization and a primary objective of the current report is to update the earlier analysis of 53 evaluations by conducting new searches for evaluations conducted and published since 2009.

Search Methods

Systematic searches were conducted using Boolean combinations of the following keywords: bully*; victim*; bully-victim; school; intervention; prevention; program*; evaluation; effect*; and anti-bullying. Searches were conducted on several online databases including, Web of Science, PscyhINFO, EMBASE, EMBASE, DARE, ERIC, Google Scholar, and Scopus. Databases of unpublished reports, such as masters' and doctoral theses (e.g., Proquest) were also searched.

Selection Criteria

Results from systematic searches were screened thoroughly against the following inclusion criteria. To be included in this review, a study must have: (1) described an evaluation of a school-based antibullying program implemented with school-age participants; (2) utilized an operational definition of school-bullying that coincides with existing definitions; (3) measured school-bullying perpetration and/or victimization using quantitative measures, such as, self-, peer-, or teacher-report questionnaires; and (4) used an experimental or quasi-experimental design, with one group receiving the intervention and another not receiving the intervention.

Data Collection and Analysis

Of the 19,877 search results, 474 were retained for further screening. The majority of these were excluded, and after multiple waves of screening, 100 evaluations were included in our meta-analysis. A total of 103 independent effect sizes were estimated and each effect size was corrected for the impact of including clusters in evaluation designs. Included evaluations were conducted using both randomized (n = 45; i.e., randomized controlled trials/RCTs) and nonrandomized (n = 44; i.e., quasi-experimental designs with before/after measures; BA/EC) methodologies. All of these studies included measures of bullying outcomes before and after implementation of an intervention. The remaining 14 effect sizes were estimated from evaluations that used age cohort designs. Two models of meta-analysis are used to report results in our report. All mean effects computed are presented using both the multivariance adjustment model (MVA) and random effects model (RE). The MVA model assigns weights to primary studies in direct proportion to study level sampling error as with the fixed effects model but adjusts the meta-analytic standard error and confidence intervals for study heterogeneity. The RE model incorporates between-study heterogeneity into the formula for assigning weights to primary studies. The differences and strengths/limitations of both approaches are discussed in the context of the present data.

Results

Our meta-analysis identified that bullying programs significantly reduce bullying perpetration (RE: odds ratio [OR] = 1.309; 95% confidence interval [CI]: 1.24-1.38; z = 9.88; p < .001) and bullying victimization (RE: OR = 1.244; 95% CI: 1.19-1.31; z = 8.92; p < .001), under a random effects model of meta-analysis. Mean effects were similar across both models of meta-analysis for bullying perpetration (i.e., MVA: OR = 1,324; 95% CI: 1.27-1.38; z = 13.4; p < .001) and bullying victimization (i.e., MVA: OR = 1.248; 95% CI: 1.21-1.29; z = 12.06; p < .001). Under both computational models, primary studies were more effective in reducing bullying perpetration than victimization overall. Effect sizes varied across studies, with significant heterogeneity between studies for both bullying perpetration (Q = 323.392; df = 85; p < .001; I 2  = 73.716) and bullying victimization (Q = 387.255; df = 87; p < .001; I 2  = 77.534) outcomes. Analyses suggest that publication bias is unlikely. Between-study heterogeneity was expected, given the large number of studies included, and thus, the number of different programs, methods, measures and samples used.

Authors' Conclusions

We conclude that overall, school-based antibullying programs are effective in reducing bullying perpetration and bullying victimization, although effect sizes are modest. The impact of evaluation methodology on effect size appears to be weak and does not adequately explain the significant heterogeneity between primary studies. Moreover, the issue of the under-/over-estimation of the true treatment effect by different experimental designs and use of self-reported measures is reviewed. The potential explanations for this are discussed, along with recommendations for future primary evaluations. Avenues for future research are discussed, including the need further explain differences across programs by correlating individual effect sizes with varying program components and varying methodological elements available across these 100 evaluations. Initial findings in the variability of effect sizes across different methodological moderators provide some understanding on the issue of heterogeneity, but future analyses based on further moderator variables are needed.

Long-Term Outcomes of the Good School Toolkit Primary School Violence Prevention Intervention Among Adolescents: Protocol for a Nonrandomized Quasi-Experimental Study

Background

Violence against children in schools is a global public health problem. There is growing evidence that school-based interventions can be effective in reducing violence against children in schools. However, there is little evidence on the long-term impact of such interventions. The Good School Toolkit, developed by Raising Voices, a Uganda-based nonprofit organization, is a whole-school violence prevention intervention that aims to change the operational culture of primary schools. In 2014, the Good School Toolkit was evaluated through a cluster randomized controlled trial (Good Schools Study) and found to reduce teacher-to-student and student-to-student violence.

Objective

This protocol describes quantitative analyses to explore long-term outcomes of the Good School Toolkit intervention among adolescents in Uganda, including the extent to which it is associated with peer-violence victimization (primary outcome) and peer-violence perpetration, intimate-partner violence, acceptance of teacher-violence, equitable gender attitudes, agency, self-regulation, peer connectedness, social assets, psychological assets, and retention in school (secondary outcomes).

Methods

This is a nonrandomized quasi-experimental 4-year follow-up study of adolescents who attended the 42 Good Schools Study primary schools in 2014; 21 schools initiated the Good School Toolkit intervention during the trial from 2012, and 19 schools initiated the intervention after the trial (during the later delivery phase) from 2015; 2 schools did not implement the intervention. Students in the final school grade (Primary 7) during 2014 of the 19 primary schools in the later delivery phase are expected to have left school prior to toolkit delivery in 2015. Wave 1 data were collected in 2014 from 3431 grade Primary 5 to Primary 7 school students aged 11-14 years; these students were followed up in 2018-2019 when aged 16-19 years and invited to participate in the Wave 2 survey. Data were collected in face-to-face interviews by trained Ugandan field researchers. Toolkit exposure groups are defined as exposed during the Good Schools Study trial (from 2012), as exposed during later delivery (from 2015), or not exposed including those expected to have completed Primary 7 prior to later delivery or from the 2 schools that did not implement the toolkit. Associations between outcomes at Wave 2 and toolkit exposure groups will be analyzed using mixed-effect multivariable logistic and linear regression models for binary and continuous outcomes, respectively. This analysis is exploratory and aims to generate hypotheses on if, and under what circumstances, the toolkit influences later adolescent outcomes.

Results

Data collection was completed in August 2019.

Conclusions

To our knowledge, this is the first long-term follow-up study of adolescents exposed to a school-based violence-prevention intervention in sub-Saharan Africa. If the intervention reduces violence and improves other outcomes in later adolescence, then this study supports primary school interventions as key to achieving long-term population impacts. The pattern of effects will inform where reinforced or additional interventions are needed.

International Registered Report Identifier (IRRID)

DERR1-10.2196/20940

Identifying pathways for large-scale implementation of a school-based mental health programme in the Eastern Mediterranean Region: a theory-driven approach

Globally there is a substantial burden of mental health problems among children and adolescents. Task-shifting/task-sharing mental health services to non-specialists, e.g. teachers in school settings, provide a unique opportunity for the implementation of mental health interventions at scale in low- and middle-income countries (LMICs). There is scant information to guide the large-scale implementation of school-based mental health programme in LMICs. This article describes pathways for large-scale implementation of a School Mental Health Program (SMHP) in the Eastern Mediterranean Region (EMR). A collaborative learning group (CLG) comprising stakeholders involved in implementing the SMHP including policymakers, programme managers and researchers from EMR countries was established. Participants in the CLG applied the theory of change (ToC) methodology to identify sets of preconditions, assumptions and hypothesized pathways for improving the mental health outcomes of school-aged children in public schools through implementation of the SMHP. The proposed pathways were then validated through multiple regional and national ToC workshops held between January 2017 and September 2019, as the SMHP was being rolled out in three EMR countries: Egypt, Pakistan and Iran. Preconditions, strategies and programmatic/contextual adaptations that apply across these three countries were drawn from qualitative narrative summaries of programme implementation processes and facilitated discussions during biannual CLG meetings. The ToC for large-scale implementation of the SMHP in the EMR suggests that identifying national champions, formulating dedicated cross-sectoral (including the health and education sector) implementation teams, sustained policy advocacy and stakeholders engagement across multiple levels, and effective co-ordination among education and health systems especially at the local level are among the critical factors for large-scale programme implementation. The pathways described in this paper are useful for facilitating effective implementation of the SMHP at scale and provide a theory-based framework for evaluating the SMHP and similar programmes in the EMR and other LMICs.

Similarities and differences in program registers: A case study

Researchers, clinicians, and other professionals are increasingly in need of cost-effective, evidence-based programs and practices. However, these individuals may lack the time and, for some, the required expertise to search for and identify such interventions. To address this concern, several online registers that list or categorize programs according to their empirical evidence of effectiveness have been established. Although these registers are designed to simplify the task of selecting evidence-based interventions, the use of distinct review processes and standards by each register creates discrepancies in final program classifications, which can pose a challenge for users. The present case study highlights three programs that have been evaluated by more than one register and have received similar or different classifications. Reasons for inconsistencies are discussed, and several recommendations for evaluating organizations and register users are provided to enhance the functionality and ease of use of online program registers.

A Critical Review of Anti-Bullying Programs in North American Elementary Schools

BACKGROUND

Bullying behavior is a concern among school-aged youth and anti-bullying programs have been implemented in schools throughout North America. Most anti-bullying programs are delivered to adolescent youth because antisocial-aggressive behaviors are typically associated with this developmental stage. This paper is a review of empirically evaluated school-based bullying prevention and intervention programs in North American elementary schools.

METHODS

We conducted a systematic, critical review of bullying prevention programming. Data were analyzed to determine the study method, intervention components, measurement of bullying, aggression, or peer victimization, outcomes measured, and results.

RESULTS

Our review resulted in the identification of 10 interventions aimed at youth in grades K-6 enrolled in North American elementary schools. Effective intervention strategies targeted a variety of bullying behaviors using diverse mechanisms and included a school-and community-wide approach. Direct outcomes of the reviewed evaluations were centered on bullying, aggression, and victimization. Indirect outcomes of review evaluations included strategies for bystanders, school achievement, perceived school safety, and knowledge or attitudes about bullying.

CONCLUSIONS

Recommendations for promising practices in effective bullying intervention programming are offered. The review concludes with suggestions for supporting school health staff and in-service teachers drawn from the body of research, and offers direction for future study.

Interventions integrating health and academic education in schools to prevent substance misuse and violence: a systematic review

Background

Schools struggle to timetable health education. Interventions integrating academic and health education to reduce substance use and violence offer promise. No current systematic reviews examine such interventions.

Objectives

To review evidence to explore the following questions: (1) what types of interventions integrating health and academic education in schools serving those aged 4–18 years have been evaluated? (2) What theories of change inform these interventions? (3) What factors facilitate or limit the successful implementation and receipt of such interventions, and what are the implications for the delivery of such implementations in the UK? (4) How effective are such interventions in reducing smoking and violence and the use of alcohol and drugs, and at increasing attainment? Does this vary by students’ sociodemographic characteristics? (5) What factors appear to influence the effectiveness of such interventions?

Data sources

In total, 19 databases were searched from 18 November to 22 December 2015, updating searches for outcome evaluations for violence on 28 February 2018 and for substance use on 14 May 2018. References were extracted from included studies and authors contacted.

Review methods

Included studies reported on theories of change, and process or outcome evaluations of interventions that integrated academic and health education to reduce substance use and/or violence. References were screened on the title/abstract and then on the full report. Data extraction and appraisal used Cochrane, Evidence for Policy and Practice Information Centre and other established tools. Theories of change and process data were qualitatively synthesised. Outcome evaluations were synthesised narratively and meta-analytically.

Results

In total, 78,451 unique references were originally identified and 62 reports included. Search updates on 28 February and 14 May 2018 retrieved a further 2355 and 1945 references, respectively, resulting in the inclusion of six additional reports. Thirty-nine reports described theories, 16 reports (15 studies) evaluated process and 41 reports (16 studies) evaluated outcomes. Multicomponent interventions are theorised to erode ‘boundaries’ (strengthen relationships) between academic and health education, teachers and students, behaviour in classrooms and in the wider school, and schools and families. Teachers, pro-social peers and parents are theorised to act as role models and reinforcers of healthy behaviours learnt in lessons. There was clear evidence that interventions are facilitated by supportive senior management and alignment with the schools’ ethos, collaborative and supportive teaching environments, and positive pre-existing student, teacher and parent attitudes towards interventions. The barriers were overburdened teachers who had little time to both learn and implement integrated curricula. The strongest evidence for effectiveness was found for the reduction of substance use in school key stages (KSs) 2 and 3. For example, a meta-analysis for substance use at KS3 reported a mean difference of –0.09 (95% confidence interval –0.17 to –0.01). A meta-analysis for effectiveness in reducing violence victimisation in KS2 found no effect. There was mixed evidence for effects on academic outcomes, with meta-analysis precluded by methodological heterogeneity.

Limitations

Study quality was variable. Integration was sometimes not emphasised in theories of change.

Conclusions

These interventions are undertheorised but involve multiple forms of boundary erosion. There is clear evidence of characteristics affecting implementation. Interventions are likely to have the greatest impact on substance use. These programmes may be effective in reducing substance use but do not appear to reduce violence and findings on educational impacts are mixed.

Future work

Future evaluations should assess interventions with clearer theories of change and examine academic outcomes alongside violence and substance use outcomes.

Study registration

This study is registered as PROSPERO CRD42015026464.

Funding

The National Institute for Health Research Public Health Research programme.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence

BACKGROUND

Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities.

METHODS

Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents.

RESULTS

Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25).

CONCLUSIONS

The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Integration of academic and health education for the prevention of physical aggression and violence in young people: systematic review, narrative synthesis and intervention components analysis

OBJECTIVES

To systematically review evidence on the effectiveness of interventions including integration of academic and health education for reducing physical aggression and violence, and describe the content of these interventions.

DATA SOURCES

Between November and December 2015, we searched 19 databases and 32 websites and consulted key experts in the field. We updated our search in February 2018.

ELIGIBILITY CRITERIA

We included randomised trials of school-based interventions integrating academic and health education in students aged 4-18 and not targeted at health-related subpopulations (eg, learning or developmental difficulties). We included evaluations reporting a measure of interpersonal violence or aggression.

DATA EXTRACTION AND ANALYSIS

Data were extracted independently in duplicate, interventions were analysed to understand similarities and differences and outcomes were narratively synthesised by key stage (KS).

RESULTS

We included 13 evaluations of 10 interventions reported in 20 papers. Interventions included either full or partial integration, incorporated a variety of domains beyond the classroom, and used literature, local development or linking of study skills and health promoting skills. Evidence was concentrated in KS2, with few evaluations in KS3 or KS4, and evaluations had few consistent effects; evaluations in KS3 and KS4 did not suggest effectiveness.

DISCUSSION

Integration of academic and health education may be a promising approach, but more evidence is needed. Future research should consider the 'lifecourse' aspects of these interventions; that is, do they have a longitudinal effect? Evaluations did not shed light on the value of different approaches to integration.

Does integrated academic and health education prevent substance use? Systematic review and meta-analyses

BACKGROUND

Prevention of substance (alcohol, tobacco, illegal/legal drug) use in adolescents is a public health priority. As the scope for school-based health education is constrained in school timetables, interventions integrating academic and health education have gained traction in the UK and elsewhere, though evidence for their effectiveness remains unclear. We sought to synthesize the effectiveness of interventions integrating academic and health education for the prevention of substance use.

METHODS

We searched 19 databases between November and December 2015, among other methods. We included randomized trials of interventions integrating academic and health education targeting school students aged 4-18 and reporting substance use outcomes. We excluded interventions for specific health-related subpopulations (e.g., children with behavioural difficulties). Data were extracted independently in duplicate. Outcomes were synthesized by school key stage (KS) using multilevel meta-analyses, for substance use, overall and by type.

RESULTS

We identified 7 trials reporting substance use. Interventions reduced substance use generally in years 7-9 (KS3) based on 5 evaluations (d = -0.09, 95% CI [-0.17, -0.01], I²  = 35%), as well as in years 10-11 (KS4) based on 3 evaluations (-0.06, [-0.09, -0.02]; I²  = 0%). Interventions were broadly effective for reducing specific alcohol, tobacco, and drug use in both KS groups.

CONCLUSIONS

Evidence quality was highly variable. Findings for years 3-6 and 12-13 could not be meta-analysed, and we could not assess publication bias. Interventions appear to have a small but significant effect reducing substance use. Specific methods of integrating academic and health education remain poorly understood.

Scope, Scale, and Dose of the World's Largest School-Based Mental Health Programs

Untreated mental health problems are among the most disabling, persistent, and costly health conditions. Because they often begin in childhood and continue into adulthood, there has been growing interest in preventive mental health programs for children. In recent years, several such programs have been implemented at regional, state, or national scale, and although many experimental studies have documented positive outcomes of individual programs, this article represents the first attempt to systematically compare the largest programs in terms of scope, scale, and dose. The school-based mental health programs discussed in this review appear to have reached more than 27 million children over the last decade, and many of these programs have collected systematic outcomes data. The role that such programs can play in low- and middle-income countries (LMICs) is a secondary focus of this article. Until recently, wide-scaled, preventive, mental health interventions for children have been studied almost exclusively in high-income countries even though around 80% of the global population of children reside in LMICs. Since a number of programs are now operating on a large scale in LMICs, it has become possible to consider child mental health programs from a more global perspective. With both the increasing diversity of countries represented and the growing scale of programs, data sets of increasing quality and size are opening up new opportunities to assess the degree to which preventive interventions for child mental health, delivered at scale, can play a role in improving health and other life outcomes.

The Effectiveness of School-Based Mental Health Services for Elementary-Aged Children: A Meta-Analysis

OBJECTIVE

Given problems and disparities in the use of community-based mental health services for youth, school personnel have assumed frontline mental health service roles. To date, most research on school-based services has evaluated analog educational contexts with services implemented by highly trained study staff, and little is known about the effectiveness of school-based mental health services when implemented by school professionals.

METHOD

Random-effects meta-analytic procedures were used to synthesize effects of school-based mental health services for elementary school-age children delivered by school personnel and potential moderators of treatment response. Forty-three controlled trials evaluating 49,941 elementary school-age children met the selection criteria (mean grade 2.86, 60.3% boys).

RESULTS

Overall, school-based services demonstrated a small-to-medium effect (Hedges g = 0.39) in decreasing mental health problems, with the largest effects found for targeted intervention (Hedges g = 0.76), followed by selective prevention (Hedges g = 0.67), compared with universal prevention (Hedges g = 0.29). Mental health services integrated into students' academic instruction (Hedges g = 0.59), those targeting externalizing problems (Hedges g = 0.50), those incorporating contingency management (Hedges g = 0.57), and those implemented multiple times per week (Hedges g = 0.50) showed particularly strong effects.

CONCLUSION

Considering serious barriers precluding youth from accessing necessary mental health care, the present meta-analysis suggests child psychiatrists and other mental health professionals are wise to recognize the important role that school personnel, who are naturally in children's lives, can play in decreasing child mental health problems.

Effectiveness of a pragmatic school-based universal resilience intervention in reducing tobacco, alcohol and illicit substance use in a population of adolescents: cluster-randomised controlled trial

OBJECTIVES

Initiation of tobacco, alcohol and illicit substance use typically occurs during adolescence, with the school setting recommended to reduce adolescent substance use. Strengthening individual (eg, problem solving) and environmental (eg, caring relationships at school) resilience protective factors of adolescents has been suggested as a strategy for reducing substance use by adolescents; however, few studies have examined this potential. A study was conducted to investigate the effectiveness of a pragmatic school-based universal 'resilience' intervention in reducing the prevalence of tobacco, alcohol and illicit substance use, and increasing the individual and environmental protective factors of students.

DESIGN

A cluster-randomised controlled trial.

SETTING

Thirty-two Australian secondary schools (20 intervention; 12 control).

PARTICIPANTS

Cohort of grade 7 students followed-up in grade 10 (2014; aged 15-16 years).

INTERVENTION

A pragmatic intervention involving school staff selection and implementation of available programmes and resources targeting individual and environmental 'resilience' protective factors for all grade 7-10 students was implemented in schools (2012-2014). School staff were provided implementation support.

MEASUREMENTS

An online survey collected baseline and follow-up data for primary outcomes: tobacco (ever, recent) and alcohol (ever, recent, 'risk') use, and secondary outcomes: marijuana and other illicit substance use, and individual (six-factor subscales, aggregate) and environmental (three-factor subscales, aggregate) protective factor scores. Generalised and linear mixed models examined follow-up differences between groups.

RESULTS

Follow-up data from 2105 students (intervention=1261; control=844; 69% of baseline cohort) were analysed. No significant differences were found between intervention and control students for any primary (ever tobacco: OR 1.25, 95% CI 0.92 to 1.68, p=0.14; recent tobacco: OR 1.39, 95% CI 0.84 to 2.31, p=0.19; recent ever alcohol: OR 1.11, 95% CI 0.83 to 1.48, p=0.46; alcohol: OR 1.13, 95% CI 0.78 to 1.62, p=0.51; 'risk' alcohol: OR 0.98, 95% CI 0.70 to 1.36, p=0.89) or secondary outcomes (marijuana: OR 1.12, 95% CI 0.74 to 1.68, p=0.57; other illicit substance: OR 1.19, 95% CI 0.67 to 2.10, p=0.54; individual protective factors: MD=0, 95% CI -0.07 to 0.06, p=0.89; environmental protective factors: MD: -0.02, 95% CI -0.09 to 0.06, p=0.65).

CONCLUSIONS

The universally implemented pragmatic school-based intervention was not effective in reducing the prevalence of tobacco, alcohol or illicit substance use, or in increasing the protective factors of students.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register reference: ACTRN12611000606987.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Can Universal SEL Programs Benefit Universally? Effects of the Positive Action Program on Multiple Trajectories of Social-Emotional and Misconduct Behaviors

Behavioral trajectories during middle childhood are predictive of consequential outcomes later in life (e.g., substance abuse, violence). Social and emotional learning (SEL) programs are designed to promote trajectories that reflect both growth in positive behaviors and inhibited development of negative behaviors. The current study used growth mixture models to examine effects of the Positive Action (PA) program on behavioral trajectories of social-emotional and character development (SECD) and misconduct using data from a cluster-randomized trial that involved 14 schools and a sample of predominately low-income, urban youth followed from 3rd through 8th grade. For SECD, findings indicated that PA was similarly effective at improving trajectories within latent classes characterized as "high/declining" and "low/stable". Favorable program effects were likewise evident to a comparable degree for misconduct across observed latent classes that reflected "low/rising" and "high/rising" trajectories. These findings suggest that PA and perhaps other school-based universal SEL programs have the potential to yield comparable benefits across subgroups of youth with differing trajectories of positive and negative behaviors, making them promising strategies for achieving the intended goal of school-wide improvements in student outcomes.

Supporting Students: A GRADE Analysis of the Research on Student Wellness and Classroom Mental Health Support

Recommendations derived from research evidence regarding program implementation in school-based mental health [SBMH] require knowledge of the intervention outcomes as well as the potential to translate program components into schools. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) analysis was applied to major areas of the SBMH literature in addressing the areas of effectiveness and the strength of recommendation in implementation. Nine areas were addressed: emotional intelligence, stigma reduction, mindfulness, anxiety, depression, addictions, suicide prevention, trauma, and eating disorders. Ninety-eight studies were retrieved across the nine areas. Effect sizes based on reported outcomes and estimates on the strength of recommendation were generated in each of the nine areas of interest. These results provide an overview of the quality of the evidence that will be of relevance to school personal in making program selections.

Meeting the Challenges of Longitudinal Cluster-Based Trials in Schools: Lessons From the Chicago Trial of Positive Action

We describe challenges in the 6-year longitudinal cluster randomized controlled trial (CRCT) of Positive Action (PA), a social-emotional and character development (SECD) program, conducted in 14 low-income, urban Chicago Public Schools. Challenges pertained to logistics of study planning (school recruitment, retention of schools during the trial, consent rates, assessment of student outcomes, and confidentiality), study design (randomization of a small number of schools), fidelity (implementation of PA and control condition activities), and evaluation (restricted range of outcomes, measurement invariance, statistical power, student mobility, and moderators of program effects). Strategies used to address the challenges within each of these areas are discussed. Incorporation of lessons learned from this study may help to improve future evaluations of longitudinal CRCTs, especially those that involve evaluation of school-based interventions for minority populations and urban areas.

The Health Promoting Schools Framework: Known Unknowns and an Agenda for Future Research

The World Health Organization’s Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools’ “core business” by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children’s basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools.

Teachers' Perceptions of School Organizational Climate as Predictors of Dosage and Quality of Implementation of a Social-Emotional and Character Development Program

Organizational climate has been proposed as a factor that might influence a school's readiness to successfully implement school-wide prevention programs. The aim of this study was to evaluate the influence of teachers' perceptions of three dimensions of school organizational climate on the dosage and quality of teacher implementation of Positive Action, a social-emotional and character development (SECD) program. The dimensions measured were teachers' perceptions of (a) the school's openness to innovation, (b) the extent to which schools utilize participatory decision-making practices, and (c) the existence of supportive relationships among teachers (teacher-teacher affiliation). Data from 46 teachers in seven schools enrolled in the treatment arm of a longitudinal, cluster-randomized, controlled trial were analyzed. Teacher perceptions of a school's tendency to be innovative was associated with a greater number of lessons taught and self-reported quality of delivery, and teacher-teacher affiliation was associated with a higher use of supplementary activities. The findings suggest that perceptions of a school's organizational climate impact teachers' implementation of SECD programs and have implications for school administrators and technical assistance providers as they work to implement and sustain prevention programs in schools.

Effects of a School-Based Social-Emotional and Character Development Program on Health Behaviors: A Matched-Pair, Cluster-Randomized Controlled Trial

There is considerable research that suggests that school-based social-emotional programs can foster improved mental health and reduce problem behaviors for participating youth; in contrast, much less is known about the impact of these programs on physical health, even though some of these programs also include at least limited direct attention to promoting physical health behaviors. We examined the effects of one such program, Positive Action (PA), on physical health behaviors and body mass index (BMI), and tested for mediation of program effects through a measure of social-emotional and character development (SECD). Participating schools in the matched-pair, cluster-randomized trial were 14 low-performing K-8 Chicago Public Schools. We followed a cohort of students in each school from grades 3 to 8 (eight waves of data collection; 1170 total students). Student self-reports of health behaviors served as the basis for measures of healthy eating and exercise, unhealthy eating, personal hygiene, consistent bedtime, and SECD. We collected height and weight measurements at endpoint to calculate age- and gender-adjusted BMI z-scores. Longitudinal multilevel modeling analyses revealed evidence of favorable program effects on personal hygiene [effect size (ES) = 0.48], healthy eating and exercise (ES = 0.21), and unhealthy eating (ES = -0.19); in addition, BMI z-scores were lower among students in PA schools at endpoint (ES = -0.21). Program effects were not moderated by either gender or student mobility. Longitudinal structural equation modeling demonstrated mediation through SECD for healthy eating and exercise, unhealthy eating, and personal hygiene. Findings suggest that a SECD program without a primary focus on health behavior promotion can have a modest impact on outcomes in this domain during the childhood to adolescence transition.

A Longitudinal Evaluation of the Positive Action Program in a Low-Income, Racially Diverse, Rural County: Effects on Self-Esteem, School Hassles, Aggression, and Internalizing Symptoms

Positive Action is a school-based program that aims to decrease problem behaviors (e.g., violence, substance use) and increase positive behaviors (e.g., school engagement, academic achievement). Although a number of studies have shown that Positive Action successfully achieves these goals, few studies have evaluated the program's effectiveness in rural schools. Given that rural youth are at an increased risk for risky behaviors (e.g., violence, substance use), this is a critical gap in the existing Positive Action research base. The current study assesses the impact of Positive Action on change rates of self-esteem, school hassles, aggression, and internalizing symptoms in a group (N = 1246, 52% female) of ethnically/racially diverse (27% White, 23% African American, 12% mixed race/other, 8% Latino, 30% as American Indian) middle school youth (age range 9-20) located in two violent, low-income rural counties in North Carolina. One county engaged in Positive Action over the 3-year study window while the other county did not. Following multiple imputation and propensity score analysis, 4 two-level hierarchical linear models were run using each of the outcome measures as dependent variables. The results indicate that the program generates statistically significant beneficial effects for youth from the intervention county on self-esteem scores and school hassles scores. Although the program generates beneficial effects for intervention youth on the change in aggression scores, the finding is not statistically significant. The finding on the change in internalizing scores shows a non-significant detrimental effect: the youth from the comparison county have lower internalizing scores than those from the intervention county. Implications are discussed.

Effects of the Positive Action Program on Indicators of Positive Youth Development Among Urban Youth

This study evaluated effects of Positive Action, a school-based social-emotional and character development (SECD) intervention, on indicators of positive youth development (PYD) among a sample of low-income, ethnic minority youth attending 14 urban schools. The study used a matched-pair, cluster-randomized controlled design at the school level. A multiple-measure self-report protocol assessed four key strengths and resources for PYD: self-concept, peer affiliations, ethics, and social skills. Students (n=1170) were assessed from grades 3 to 8, the duration of the intervention, with drop-outs and late entrants included in analyses. Growth curve analyses revealed evidence of favorable program effects on each of the four types of resources. The study contributes to PYD research by providing evidence for school-based interventions in low-income, urban contexts for ethnic minority youth.

Interventions on bullying and cyberbullying in schools: a systematic review

Background : bullying (and cyberbullying) is a widespread phenomenon among young people and it is used to describe interpersonal relationships characterized by an imbalance of power. In this relationships often show aggressive behavior and intentional "harm doing" repeated over time. The prevalence of bullying among youth has been reported to vary widely among countries (5.1%-41.4%) and this behavior seems generally higher among student boys than girls. Several school interventions have been developed to reduce bullying, but reported inconsistent results possibly related to limitations in the study design or to other methodological shortcomings. Aims : evaluating randomized-controlled trials (RTCs) conducted between 2000 and 2013 to assess the effectiveness of school interventions on bullying and cyberbullying. Methods : a systematic search of the scientific literature was conducted on Pubmed/Medline and Ebsco online databases. We also contacted experts in the field of preventive bullying research. Results : 17 studies met the inclusion criteria. The majority of studies did not show positive effects in the long term; the interventions focused on the whole school were more effective in reducing bullying than interventions delivered through classroom curricula or social skills training alone. Conclusion : while there is evidence that programs aimed at reducing bullying can be effective in the short term, their long-term effectiveness has not been established, and there are important differences in the results based on gender, age and socio-economic status of participants. Internal inconsistency in the findings of some studies, together with the wide variability of experimental designs and lack of common standardized measures in outcome evaluation, are important limitations in this field of research.

The World Health Organization's Health Promoting Schools framework: a Cochrane systematic review and meta-analysis

BACKGROUND

Healthy children achieve better educational outcomes which, in turn, are associated with improved health later in life. The World Health Organization's Health Promoting Schools (HPS) framework is a holistic approach to promoting health and educational attainment in school. The effectiveness of this approach has not yet been rigorously reviewed.

METHODS

We searched 20 health, education and social science databases, and trials registries and relevant websites in 2011 and 2013. We included cluster randomised controlled trials. Participants were children and young people aged four to 18 years attending schools/colleges. HPS interventions had to include the following three elements: input into the curriculum; changes to the school's ethos or environment; and engagement with families and/or local communities. Two reviewers identified relevant trials, extracted data and assessed risk of bias. We grouped studies according to the health topic(s) targeted. Where data permitted, we performed random-effects meta-analyses.

RESULTS

We identified 67 eligible trials tackling a range of health issues. Few studies included any academic/attendance outcomes. We found positive average intervention effects for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small. On average across studies, we found little evidence of effectiveness for zBMI (BMI, standardized for age and gender), and no evidence for fat intake, alcohol use, drug use, mental health, violence and bullying others. It was not possible to meta-analyse data on other health outcomes due to lack of data. Methodological limitations were identified including reliance on self-reported data, lack of long-term follow-up, and high attrition rates.

CONCLUSION

This Cochrane review has found the WHO HPS framework is effective at improving some aspects of student health. The effects are small but potentially important at a population level.

Teachers' Perceptions of School Organizational Climate as Predictors of Dosage and Quality of Implementation of a Social-Emotional and Character Development Program

Organizational climate has been proposed as a factor that might influence a school's readiness to successfully implement school-wide prevention programs. The aim of this study was to evaluate the influence of teachers' perceptions of three dimensions of school organizational climate on the dosage and quality of teacher implementation of Positive Action, a social-emotional and character development (SECD) program. The dimensions measured were teachers' perceptions of (a) the school's openness to innovation, (b) the extent to which schools utilize participatory decision-making practices, and (c) the existence of supportive relationships among teachers (teacher-teacher affiliation). Data from 46 teachers in seven schools enrolled in the treatment arm of a longitudinal, cluster-randomized, controlled trial were analyzed. Teacher perceptions of a school's tendency to be innovative was associated with a greater number of lessons taught and self-reported quality of delivery, and teacher-teacher affiliation was associated with a higher use of supplementary activities. The findings suggest that perceptions of a school's organizational climate impact teachers' implementation of SECD programs and have implications for school administrators and technical assistance providers as they work to implement and sustain prevention programs in schools.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

A systematic review of effective interventions for reducing multiple health risk behaviors in adolescence

We systematically searched 9 biomedical and social science databases (1980-2012) for primary and secondary interventions that prevented or reduced 2 or more adolescent health risk behaviors (tobacco use, alcohol use, illicit drug use, risky sexual behavior, aggressive acts). We identified 44 randomized controlled trials of universal or selective interventions and were effective for multiple health risk behaviors. Most were school based, conducted in the United States, and effective for multiple forms of substance use. Effects were small, in line with findings for other universal prevention programs. In some studies, effects for more than 1 health risk behavior only emerged at long-term follow-up. Integrated prevention programs are feasible and effective and may be more efficient than discrete prevention strategies.

SOCIO-EMOTIONAL AND CHARACTER DEVELOPMENT: A Theoretical Orientation

More and more researchers are studying socio-emotional and character development (SECD). The rise and progress in SECD research is encouraging, but there is a critical issue with such a multidisciplinary and fast-developing field: SECD research and evaluation can be more consistent to prevent heterogeneity in definitions and disparate theoretical, measurement, and program models. After summarizing SECD-related literature, I recommend the theory of triadic influence (TTI) as a force to generate consistency and a resource to assist in guiding the design and evaluation of SECD-related programs. The theory fills a gulf in the literature that seeks an ecological theory aligned with SECD-related programs and etiology. The recommendation of the TTI stems from 3 main advantages: (1) The TTI integrates a full range of risk and protective factors in a detailed mediation and moderation framework; (2) it takes a comprehensive view of all the stakeholders in the educational system (i.e., youth, schools, families, and communities); (3) and its utility has been substantiated by empirical evidence from a variety of fields. I discuss applications of the TTI in SECD-related work and suggest improvements for etiology research and the design and evaluation of SECD programs.

Effects of Positive Action on the emotional health of urban youth: a cluster-randomized trial

PURPOSE

We examined the effects of Positive Action (PA), a school-based social-emotional learning and health promotion program, on the emotional health of predominately low-income and ethnic minority urban youth.

METHODS

The study was a matched-pair, cluster-randomized controlled trial involving 14 Chicago public schools. Outcomes were assessed over a 6-year period of program implementation for a cohort of youth in each school, followed from grades 3 to 8. Youth reported on their emotional health (positive affect, life satisfaction, depression, anxiety) and social-emotional and character development. Growth-curve and structural-equation modeling analyses assessed overall program effects on the emotional health outcomes as well as mediation of these effects via the program's impact on youths' social-emotional and character development.

RESULTS

Students in PA schools, compared with those in control schools, had more favorable change over the course of the study in positive affect (standardized mean difference effect size [ES] = .17) and life satisfaction (ES = .13) as well as significantly lower depression (ES = -.14) and anxiety (ES = -.26) at study end point. Program effects for positive affect, depression, and anxiety were mediated by more favorable change over time in social-emotional and character development for students in PA schools.

CONCLUSIONS

Results suggest that universal, school-based programs can benefit the emotional health of youth in low-income, urban settings. The modest magnitude of effects over an extended period of program implementation, however, reflects the challenges of both mounting interventions and offsetting formidable risks for mental health problems in such environments.

Using social-emotional and character development to improve academic outcomes: a matched-pair, cluster-randomized controlled trial in low-income, urban schools

BACKGROUND

School-based social-emotional and character development (SECD) programs can influence not only SECD but also academic-related outcomes. This study evaluated the impact of one SECD program, Positive Action (PA), on educational outcomes among low-income, urban youth.

METHODS

The longitudinal study used a matched-pair, cluster-randomized controlled design. Student-reported disaffection with learning and academic grades, and teacher ratings of academic ability and motivation were assessed for a cohort followed from grades 3 to 8. Aggregate school records were used to assess standardized test performance (for entire school, cohort, and demographic subgroups) and absenteeism (entire school). Multilevel growth-curve analyses tested program effects.

RESULTS

PA significantly improved growth in academic motivation and mitigated disaffection with learning. There was a positive impact of PA on absenteeism and marginally significant impact on math performance of all students. There were favorable program effects on reading for African American boys and cohort students transitioning between grades 7 and 8, and on math for girls and low-income students.

CONCLUSIONS

A school-based SECD program was found to influence academic outcomes among students living in low-income, urban communities. Future research should examine mechanisms by which changes in SECD influence changes in academic outcomes.

Problem behavior and urban, low-income youth: a randomized controlled trial of positive action in Chicago

BACKGROUND

Youth problem behaviors remain a public health issue. Youth in low-income, urban areas are particularly at risk for engaging in aggressive, violent, and disruptive behaviors.

PURPOSE

To evaluate the effects of a school-based social-emotional learning and health promotion program on problem behaviors and related attitudes among low-income, urban youth.

DESIGN

A matched-pair, cluster RCT.

SETTING/PARTICIPANTS

Participants were drawn from 14 Chicago Public Schools over a 6-year period of program delivery with outcomes assessed for a cohort of youth followed from Grades 3 to 8. Data were collected from Fall 2004 to Spring 2010, and analyzed in Spring 2012.

INTERVENTION

The Positive Action program includes a scoped and sequenced K-12 classroom curriculum with six components: self-concept, social and emotional positive actions for managing oneself responsibly, and positive actions directed toward physical and mental health, honesty, getting along with others, and continually improving oneself. The program also includes teacher, counselor, family, and community training as well as activities directed toward schoolwide climate development.

MAIN OUTCOME MEASURES

Youth reported on their normative beliefs in support of aggression and on their bullying, disruptive, and violent behaviors; parents rated youths' bullying behaviors and conduct problems; schoolwide data on disciplinary referrals and suspensions were obtained from school records.

RESULTS

Multilevel growth-curve modeling analyses conducted on completion of the trial indicated that Positive Action mitigated increases over time in (1) youth reports of normative beliefs supporting aggressive behaviors and of engaging in disruptive behavior and bullying (girls only) and (2) parent reports of youth bullying behaviors (boys only). At study end-point, students in Positive Action schools also reported a lower rate of violence-related behavior than students in control schools. Schoolwide findings indicated positive program effects on both disciplinary referrals and suspensions. Program effect sizes ranged from -0.26 to -0.68.

CONCLUSIONS

These results extend evidence of the effectiveness of the Positive Action program to low-income, minority, urban school settings, and to middle school-aged youth.

Using the community readiness model as an approach to formative evaluation

This article presents an adapted version of an established model for assessing community readiness along with an illustrative case example from the evaluation of Positive Action, a school-based social and character development intervention, implemented as part of a randomized controlled trial in Chicago Public Schools from 2004 through 2010. Community readiness is an emerging assessment approach that can be used to gauge the level of understanding, desire, and ownership that community members have regarding a community problem and/or intervention. This approach is useful in engaging the community and leveraging particular aspects of readiness that the community may exhibit in order to maximize an intervention's successful implementation. The article concludes with a discussion of ways in which a community readiness model may be useful in health promotion practice, both in schools and in other community settings.

Preventing negative behaviors among elementary-school students through enhancing students' social-emotional and character development

PURPOSE

Examine the effects of a comprehensive, school-wide social-emotional and character development program using a positive youth development perspective. Specifically, we examined a mediation mechanism whereby positive academic-related behaviors mediated the intervention effects on substance use, violence, and sexual activity.

DESIGN

Matched-pair, cluster-randomized, controlled design.

SETTING

Twenty (10 intervention and 10 control) racially/ethnically diverse schools in Hawaii.

SUBJECTS

Elementary-aged students (N = 1784) from grade 5.

INTERVENTION

The Positive Action program.

MEASURES

Students self-reported their academic behaviors, together with their substance use, violence, and voluntary sexual activity; teachers rated students' academic behaviors, substance use, and violence.

ANALYSIS

Structural equation modeling.

RESULTS

Students attending intervention schools reported significantly better academic behavior (B = .273, SE = .039, p < .001) and significantly less substance use (B = -.970, SE = .292, p < .01, incidence-rate ratio [IRR] = .379), violence (B = -1.410, SE = .296, p < .001, IRR = .244), and sexual activity (B = -2.415, SE = .608, p < .001, odds ratio = .089); boys reported more negative behaviors than girls. Intervention effects on student-reported substance use, violence, and sexual activity were mediated by positive academic behavior. Teacher reports corroborated these results, with rated academic behavior partially mediating the effects of the intervention on rated negative behaviors.

CONCLUSION

This study (1) provides evidence that adds insight into one mechanism through which a social-emotional and character development program affects negative outcomes and (2) supports social-emotional and character development and positive youth development perspectives that posit that focusing on youths' assets may reduce negative behaviors.

Improving elementary school quality through the use of a social-emotional and character development program: a matched-pair, cluster-randomized, controlled trial in Hawai'i

BACKGROUND

School safety and quality affect student learning and success. This study examined the effects of a comprehensive elementary school-wide social-emotional and character education program, Positive Action, on teacher, parent, and student perceptions of school safety and quality utilizing a matched-pair, cluster-randomized, controlled design. The Positive Action Hawai'i trial included 20 racially/ethnically diverse schools and was conducted from 2002-2003 through 2005-2006.

METHODS

School-level archival data, collected by the Hawai'i Department of Education, were used to examine program effects at 1-year post-trial. Teacher, parent, and student data were analyzed to examine indicators of school quality such as student safety and well-being, involvement, and satisfaction, as well as overall school quality. Matched-paired t-tests were used for the primary analysis, and sensitivity analyses included permutation tests and random-intercept growth curve models.

RESULTS

Analyses comparing change from baseline to 1-year post-trial revealed that intervention schools demonstrated significantly improved school quality compared to control schools, with 21%, 13%, and 16% better overall school quality scores as reported by teachers, parents, and students, respectively. Teacher, parent, and student reports on individual school-quality indicators showed improvement in student safety and well-being, involvement, satisfaction, quality student support, focused and sustained action, standards-based learning, professionalism and system capacity, and coordinated team work. Teacher reports also showed an improvement in the responsiveness of the system.

CONCLUSIONS

School quality was substantially improved, providing evidence that a school-wide social-emotional and character education program can enhance school quality and facilitate whole-school change.

Effects of a social-emotional and character development program on the trajectory of behaviors associated with social-emotional and character development: findings from three randomized trials

The effects of a school-based social-emotional and character development program, Positive Action, on the developmental trajectory of social-emotional and character-related behaviors was evaluated using data from three school-based randomized trials in elementary schools. Results come from 1) 4 years of data from students in 20 Hawai'i schools, 2) 3 years of data from students in 14 schools in Chicago and 3) 3 years of data from students in 8 schools in a southeastern state. Random intercept, multilevel, growth-curve analyses showed that students in both control and Positive Action schools exhibited a general decline in the number of positive behaviors associated with social-emotional and character development that were endorsed. However, the Positive Action intervention significantly reduced these declines in all three trials. Taken together, these analyses 1) give insight into the normative trajectory of behaviors associated with social-emotional and character development and 2) provide evidence for the effectiveness of Positive Action in helping children maintain a relatively beneficial developmental trajectory.

School-based smoking prevention programs with the promise of long-term effects

I provide a systematic review of trials of school-based smoking prevention programs that had at least 15 sessions, preferably with some in high school, that reported significant short-term effects, and that included long-term follow-up. This is supplemented with a description of some other programs that produce short-term effects that portend large long-term effects. I conclude that school-based programs can have long-term effects of practical importance it they: include 15 or more sessions over multiple years, including some in high school; use the social influence model and interactive delivery methods; include components on norms, commitment not to use, intentions not to use, and training and practice in the use of refusal and other life skills; and use peer leaders in some role. School-based programs of this type can reduce smoking onset by 25-30%, and school plus community programs can reduce smoking onset by 35-40% by the end of high school. Some early childhood programs that do not have smoking prevention as their main aim, including home nursing, the Good Behavior Game, the Positive Action program and others, seem to change the developmental trajectories of children so that they are less likely to engage in multiple problem behaviors, including smoking, as adolescents. This review makes it clear that effective school-based smoking prevention programs exist and can be adopted, adapted and deployed with success - and should be.