The safer choices project: methodological issues in school-based health promotion intervention research

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.

The skinny on sexual risk: the effects of BMI on STI incidence and risk

Few studies examine the influence of body mass index (BMI) on sexual risk. The purpose of this study was to determine whether BMI among 704 young mothers (ages 14-25) related to STI incidence and sexual risk. We examined the effect of BMI groups (normal weight, overweight, and obese) at 6 months postpartum on STI incidence and risky sex (e.g., unprotected sex, multiple partners, risky and casual partner) at 12 months postpartum. At 6 months postpartum, 31% of participants were overweight and 40% were obese. Overweight women were more likely to have an STI (OR = 1.79, 95% CI = 1.11-2.89, P < .05) and a risky partner (OR = 1.64, 95% CI = 1.01-2.08, P < .05) at 12 months postpartum compared to normal weight women. However, obese women were less likely to have an STI than normal weight women (OR = .57, 95% CI = .34-.96, P < .01). BMI related to STI incidence and sexual risk behavior. Integrated approaches to weight loss and sexual risk prevention should be explored.

HIV preventive interventions for adolescents: a look back and ahead

HIV and sexual risk continue to be central threats to the health and well-being of adolescents in the United States and abroad. Great strides have been made in creating interventions that reduce contracting and transmitting the deadly virus among adolescents. Numerous interventions have been designed and evaluated, with many having positive results in reducing adolescents' HIV risk behavior. However, the complexity of adolescents as well as limited effects on many sexual risk outcomes indicate that much more work needs to be done. This article provides a review of the literature on interventions among adolescents, summarizing why adolescents provide a unique challenge for HIV prevention, the intervention approaches that have been taken, and the challenges and recommendations for the future as the field confronts the neurobiologic dimension of risk.

Challenges in replicating interventions

PURPOSE

To describe and reflect on an effort to document, through a set of 6 interventions, the process of adapting effective youth risk behavior interventions for new settings, and to provide insights into how this might best be accomplished.

METHODS

Six studies were funded by the NIH, starting in 1999. The studies were funded in response to a Request for Applications (RFA) to replicate HIV prevention interventions for youth. Researchers were to select an HIV risk reduction intervention program shown to be effective in one adolescent population and to replicate it in a new community or different adolescent population. This was to be done while systematically documenting those processes and aspects of the intervention hypothesized to be critical to the development of community-based, culturally sensitive programs. The replication was to assess the variations necessary to gain cooperation, implement a locally feasible and meaningful intervention, and evaluate the outcomes in the new setting. The rationale for this initiative and description of the goals and approaches to adaptation of the funded researchers are described.

RESULTS

Issues relevant to all interventions are discussed, in addition to those unique to replication. The processes and the consequences of the adaptations are then discussed. The further challenges in taking a successful intervention "to scale" are not discussed.

CONCLUSIONS

Replications of effective interventions face all of the challenges of implementation design, plus additional challenges of balancing fidelity to the original intervention and sensitivity to the needs of new populations.

Hip-Hop to Health Jr. for Latino preschool children

OBJECTIVE

Hip-Hop to Health Jr. was a diet/physical activity intervention designed to reduce gains in BMI (kilograms per meter squared) in preschool minority children.

RESEARCH METHODS AND PROCEDURES

Twelve predominantly Latino Head Start centers participated in a group-randomized trial conducted between Fall 2001 and Winter 2003. Six centers were randomized to a culturally proficient 14-week (three times weekly) diet/physical activity intervention. Parents participated by completing weekly homework assignments. The children in the other six centers received a general health intervention that did not address either diet or physical activity. The primary outcome was change in BMI, and secondary outcomes were changes in dietary intake and physical activity. Measures were collected at baseline, post-intervention, and at Years 1 and 2 follow-up.

RESULTS

There were no significant differences between intervention and control schools in either primary or secondary outcomes at post-intervention, Year 1, or Year 2 follow-ups.

DISCUSSION

When Hip-Hop to Health Jr. was conducted in predominantly black Head Start centers, it was effective in reducing subsequent increases in BMI in preschool children. In contrast, when the program was conducted in Latino centers, it was not effective. Although the intervention did not prevent excessive weight gain in Latino children, it was very well received. Future interventions with this population may require further cultural tailoring and a more robust parent intervention.

Evaluation of a USDA nutrition education program for low-income youth

OBJECTIVE

Examine effectiveness of a state's Youth Expanded Food and Nutrition Education Program (EFNEP) and assess the validity of the federal impact indicator method for reporting program outcomes.

DESIGN

A randomized, controlled field trial of 229 groups with 5,111 youth, 9-12 years old, in community settings.

INTERVENTION

6- to 8- hour, 7-lesson education experience with food preparation and tasting, an education experience typical of EFNEP in California.

OUTCOME MEASURES

US Department of Agriculture (USDA) impact indicators: nutrition knowledge, eating a variety of foods, food selection, and food preparation and safety practices.

ANALYSIS

Analysis of covariance model controlling for pretest, gender, age, and ethnicity, with group nested in condition.

RESULTS

Organizing responses by impact indicators, treatment participants made significant gains on the posttest compared to controls for 3 of 4 indicators (P < .008 to P < .0001). Gains were made by 34 to 68% of youth participants for 4 indicators. The impact indicator method for federal reporting compared favorably with results from a randomized controlled trial with groups nested in conditions.

CONCLUSION AND IMPLICATIONS

This is the first report in the literature of (1) a large evaluation study of Youth EFNEP and (2) an estimate of the validity of the USDA impact indicator method for reporting program outcomes.

An analysis of health promotion and risk behaviors of freshman college students in a rural southern setting

This study described health promotion and risk behaviors of entering college students in a rural southern setting. A sample of 251 students completed the Health Promotion and Health Risk Survey during a testing period that included other academic surveys. Results indicated that participants believe they are in control of their health. In addition, participants reported that happiness and health were the most important personal values for them. When compared with the National College Health Risk Behavior data, participants in this study were significantly lower in many of the health risk behaviors.

Pathways: lessons learned and future directions for school-based interventions among American Indians

BACKGROUND

Pathways, a multicenter study to test the effect of a school-based program to prevent obesity in American Indian children, yielded many benefits and encountered many challenges. This paper explores what we have learned from this study and examines possible future directions.

METHODS

Information presented in this paper is based on formative research, study results, and discussions with staff and investigators.

RESULTS

Some of the lessons learned relate to having a strong relationship with the tribes, how best to engage the communities, the importance of formative research and achieving standardization in culturally diverse settings, how to incorporate cultural information into curricula, and the importance of family involvement. One of the strengths of the study was the collaborative process that teamed American Indian and non-American Indian investigators and staff. Researchers recognized that they must work in cooperation with research participants including their schools and communities to address challenges, to ensure accurate findings and analyses, and to share benefits.

CONCLUSIONS

The lessons learned from Pathways offer valuable insights for researchers into successful approaches to the challenges inherent in research in American Indian communities, particularly in schools, and how to maximize the benefits of such a study.

Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students

Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory-based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months afterbaseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condomuse demonstrated that aschool-based program can reduce the sexual risk behavior of adolescents.

Safer choices: reducing teen pregnancy, HIV, and STDs

OBJECTIVES

This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students.

METHODS

The study used a randomized controlled trial involving 20 high schools in California and Texas. A cohort of 3869 ninth-grade students was tracked for 31 months from fall semester 1993 (baseline) to spring semester 1996 (31-month follow-up). Data were collected using self-report surveys administered by trained data collectors. Response rate at 31-month follow-up was 79%.

RESULTS

Safer Choices had its greatest effect on measures involving condom use. The program reduced the frequency of intercourse without a condom during the three months prior to the survey, reduced the number of sexual partners with whom students had intercourse without a condom, and increased use of condoms and other protection against pregnancy at last intercourse. Safer Choices also improved 7 of 13 psychosocial variables, many related to condom use, but did not have a significant effect upon rates of sexual initiation.

CONCLUSIONS

The Safer Choices program was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.

Postponing sexual intercourse among urban junior high school students-a randomized controlled evaluation

PURPOSE

To describe a randomized, controlled evaluation of a school-based intervention to delay sexual intercourse among urban junior high school students.

METHODS

Six Washington, D.C., junior high schools were randomly assigned to the intervention or nonintervention control condition for an educational program. During the first school year, seventh graders (n = 582) from the six schools obtained written parental consent to participate. Three health professionals (one per intervention school) implemented the program, which consisted of reproductive health classes, the Postponing Sexual Involvement Curriculum, health risk screening, and "booster" educational activities during the following (eighth grade) school year. Cross-sectional surveys were administered at baseline, the end of the seventh grade, and the beginning and end of the eighth grade. Intervention and control group differences in virginity, attitudes toward delayed sex and childbearing, and sexual knowledge and behavior were assessed at all four time points.

RESULTS

At baseline, 44% of the seventh grade males and 81% of the seventh grade females reported being virgins. At the end of the seventh grade (first follow-up), after controlling for baseline study group differences, intervention-group females were more likely to report virginity, self-efficacy to refuse sex with a boyfriend, and the intention to avoid sexual involvement during the following 6 months. At the end of the eighth grade, significantly more intervention- than control-group females reported virginity, birth control use at last intercourse (for nonvirgins), and knowledge of adolescent reproductive health and confidentiality rights. No changes in virginity, self-efficacy to refuse sex, or sexual intent for the next 6 months were observed among male participants at any time during the study. However, on all three follow-up surveys, intervention-group males scored significantly higher than their control-group counterparts in knowledge of birth control method efficacy. No change in attitudes toward abstinence was observed for either gender at any follow-up point.

CONCLUSIONS

Gender differences in baseline sexual activity rates and in various study outcomes suggest a possible need for separate, gender-specific intervention activities that can adequately address the social and cognitive needs of both sexes.

Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program

This study evaluated the effectiveness of the first year of Safer Choices, a theoretically based, multicomponent HIV, STD, and pregnancy prevention program for high school youth. The study featured a randomized trial involving 20 schools in California and Texas, with a cohort of 3,869 ninth-grade students. Students who completed both the baseline and the first follow-up survey approximately seven months later were included in the analysis (n = 3,677). Safer Choices enhanced 9 of 13 psychosocial variables including knowledge, self efficacy for condom use, normative beliefs and attitudes regarding condom use, perceived barriers to condom use, risk perceptions, and parent-child communication. Safer Choices also reduced selected risk behaviors. Specifically, Safer Choices reduced the frequency of intercourse without a condom in the three months prior to the survey, increased use of condoms at last intercourse, and increased use of selected contraceptives at last intercourse.