School-based health promotion intervention: parent and school staff perspectives

Community health workers' perspectives on integrating into school settings to support student health

Introduction

While schools represent key venues for supporting health, they continue to experience gaps in health resources. The integration of community health workers (CHWs) into schools has the potential to supplement these resources but has been underexplored. This study is the first to examine perspectives of experienced CHWs about how CHWs can be applied in school settings to support student health.

Methods

This qualitative study involved conducting semi-structured interviews focused on implementation of CHWs in schools with individuals who held positions aligned with the CHW scope of work. De-identified transcripts were analyzed, and codes were organized into domains and themes.

Results

Among 14 participants, seven domains emerged about the implementation of CHWs in schools: roles and responsibilities, collaborations, steps for integration, characteristics of successful CHWs, training, assessment, and potential challenges. Participants shared various potential responsibilities of school-based CHWs, including educating on health topics, addressing social determinants of health, and supporting chronic disease management. Participants emphasized the importance of CHWs building trusting relationships with the school community and identified internal and external collaborations integral to the success of CHWs. Specifically, participants indicated CHWs and schools should together determine CHWs' responsibilities, familiarize CHWs with the school population, introduce CHWs to the school community, and establish support systems for CHWs. Participants identified key characteristics of school-based CHWs, including having familiarity with the broader community, relevant work experience, essential professional skills, and specific personal qualities. Participants highlighted trainings relevant to school-based CHWs, including CHW core skills and health topics. To assess CHWs' impact, participants proposed utilizing evaluation tools, documenting interactions with students, and observing indicators of success within schools. Participants also identified challenges for school-based CHWs to overcome, including pushback from the school community and difficulties related to the scope of work.

Discussion

This study identified how CHWs can have a valuable role in supporting student health and the findings can help inform models to integrate CHWs to ensure healthy school environments.

Parental Perspectives of Sleep in the Home: Shaping Home-School Partnerships in School-Based Sleep Promotion Initiatives

INTRODUCTION

Sleep is a critical component of child health and the prevention of chronic disease. Children may benefit from school-based sleep promotion; however, parents need to be involved for healthy sleep strategies learned at school to be translated to the home. The objective of this study was to explore parental perspectives on sleep behaviors and responsiveness to school-based sleep promotion.

METHODS

Twenty-five parents of school-aged children were purposively sampled for interviews from July 2019 through April 2020 in Alberta, Canada. Descriptive qualitative methodology was used, and data were generated through semistructured interviews and researcher field notes. Interviews were transcribed and themes were identified by using latent content analysis.

RESULTS

Three themes emerged from analysis: 1) sleep is valued and supported, 2) barriers to healthy sleep exist, and 3) schools are allies in promoting sleep. Parents perceived that sleep was essential for their child's health, facilitated healthy sleep practices in the home, and highlighted barriers (busy schedules and poor parental role models) that affected sleep. Parents supported and expressed value in school-based sleep promotion and noted factors that affected the success of school-based sleep promotion.

CONCLUSION

Parents are responsive to school-based sleep promotion. Promotion efforts should include resources that engage and involve parents in the school community. Throughout the development of resources to support school-based sleep promotion, additional consideration of parent-reported barriers to promoting healthy sleep in the home should be included.

Which factors promote and prohibit successful implementation and normalization of a healthy school lunch program at primary schools in the Netherlands?

BACKGROUND

A school provided healthy lunch might help to improve the nutritional quality of children's lunches. However, in the Netherlands, school lunch programs are not common. The aim of this study was to identify factors that promote or inhibit the implementation of a school lunch program at primary schools, from the viewpoint of school professionals.

METHODS

A cross-sectional online survey was conducted among 204 primary school professionals. The normalization process theory and its four constructs (i.e. coherence, cognitive participation, collective action, reflective monitoring) were used to develop questions and interpret findings. Descriptive statistics were used for 14 multiple choice questions (yes, no, don't know) and thematic content analysis for qualitative responses.

RESULTS

Participants had a shared understanding about how a lunch program differed from current practices. Most participants had the same view on the rationale for implementation (coherence), such as equality among children. Sixty percent expected that a healthy school lunch will contribute to healthier eating by the children. Participants showed different degrees of cognitive participation (46% indicated that healthy school lunch is good idea). Commitment depended on their belief whether providing a healthy lunch was part of their responsibility as school and 30% expected a large effect on their daily work (collective action). When appraising school lunch implementation (reflective monitoring), participants' concerns focused on feasibility and adaptability of a program in their own school.

CONCLUSIONS

The introduction of a school lunch program will require substantial effort, although there is considerable support and understanding about potential benefits. The findings point to a number of preconditions for large-scale introduction, including the need for support-both financially and organizationally-bottom-up involvement of teachers, children and parents and freedom to adapt the program.

Principals' Perspectives on Joining a Kindergarten Outreach Dental Service: A Qualitative Study

In this qualitative study, the researchers explored principals' perspectives on a free outreach dental service with silver diamine fluoride (SDF) therapy for children in kindergarten. Two researchers recruited kindergarten principals using purposive sampling. They conducted individual semi-structured interviews to collect the principals' perspectives regarding their adoption of and experience with the service. They manually transcribed the interview verbatim into text and followed a thematic approach for data analysis. The researchers interviewed eight principals. The principals identified the prevalent caries status and importance of oral health promotion for kindergarten children. They acknowledged that the service enhanced dental knowledge, fostered oral hygiene practice and improved children's oral health. To adopt this service, they needed to ensure adequate capacity to perform the service. They had no concern with staining by SDF because the parents were informed and consented to the SDF therapy. They appreciated the free service provided by a professional team managed by a reputable university. In conclusion, the principals were generally satisfied with the outreach dental service. They realised the necessity of oral health promotion. They found that parents accepted the SDF therapy although the SDF stained their children's carious teeth. They needed support from their teachers and the children's parents to run the service.

Effects of 'SPRAT' programme for dietary and lifestyle education to improve psychosomatic symptoms and dietary habits among adolescents: a cluster randomised controlled trial

BACKGROUND

Dietary and lifestyle modifications to reduce subjective psychosomatic symptoms (SPS) have become an important topic worldwide. We developed a school-based dietary and lifestyle education programme that involved parents/guardians in reducing SPS in adolescents (SPRAT). The programme encouraged parents/guardians to participate in adolescents' healthy dietary and lifestyle modifications to reduce SPS, increase enjoyment of school life, and foster appropriate dietary intake. This study evaluated the effectiveness of SPRAT in reducing SPS and in altering dietary behaviour among adolescents.

METHODS

A 6-month cluster randomised controlled trial using SPRAT and the usual school programme (control) was performed. Participants were middle school students in Japan who provided informed consent. Outcomes were SPS scores assessed at baseline and 2, 4, and 6 months after baseline and the proportions of dietary and lifestyle factors achieved such as enjoyment of school life and dietary intakes assessed by FFQW82. Change from baseline (CFB) at 6 months was the primary endpoint. A linear mixed-effects model was applied. As for dietary intake, the treatment effect was estimated as an interaction term between baseline and treatment "baseline*treatment".

RESULTS

The intention-to treat analysis included 951 (94.7%) and 1035 (89.8%) individuals in the SPRAT and control groups, respectively. The CFB in the 6-month SPS score adjusted for baseline was lower in the SPRAT group (-0.29) than in the control group (0.62), but the difference was not statistically significant -0.91 (p = 0.093).

CONCLUSIONS

Although the primary endpoint tended to denote improvement in the SPRAT group compared to the control group, the improvement was not significant. Favourable effects were observed in some secondary outcomes and statistically significant treatment*baseline interactions were observed for several dietary intakes. These results imply that CFBs of dietary intake were increased or decreased in a favourable direction depending on the baseline intake, especially in the SPRAT group.

TRIAL REGISTRATION

UMIN000026715. (27/03/2017).

"When I feel well all over, I study and learn better" - experiences of good conditions for health and learning in schools in the Arctic region of Sweden

A challenge facing the Arctic region is the disengagement of both education and work among its youth. Only by supporting young people who are struggling with mental and physical health challenges can we begin to address this societal challenge. Education, mental health and social inclusion are prominent factors for future employment, income and independent living for young people. The aim of this study was to describe and understand the experiences of good conditions for health and learning in schools in the Arctic region. The 5-D appreciative inquiry method was used to explore 47 students’ and professionals’ experiences and future visions of their school. A phenomenological analysis resulted in three themes: “Standing as one”, “Having an apple a day”, and “Finding the end of the rainbow”. The findings revealed the necessity of promoting health and learning simultaneously in school and viewing health holistically. Health-promoting relationships permeate the findings of good conditions for health and learning. We argue for considering mandatory health education to increase students’ health literacy and making student participation and staff collaboration a priority in schools in the Arctic region. These findings, their practical implications, and future research directions are discussed.

Identifying factors associated with overweight and obesity among intermediate school students aged 12-15 years in school settings: mixed-methodology protocol

INTRODUCTION

Childhood obesity is a public health concern globally. In Arab countries, the prevalence of overweight and obesity has increased significantly over the last three decades. The level of childhood overweight and obesity in the Kingdom of Saudi Arabia (KSA) is high and continues to increase. This study will explore factors associated with overweight and obesity among adolescents and identify barriers and enablers to the implementation of comprehensive school-based obesity prevention interventions.

METHODS AND ANALYSIS

Socioecological model will inform this mixed-methods study. The study will include three phases: (1) a scoping review of the literature; (2) the development of a student survey instrument and (3) a mixed-method study comprising a cross-sectional survey targeting students aged 12-15 years with the collection of the students' height and weight measurements; one-on-one interviews with physical education teachers and school principals; and the administration of school climate audits using the Health Promoting School framework. Reliability and validity of the survey instrument will be examined during survey development. Descriptive, inferential and thematic analysis will be employed using appropriate statistical software.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Curtin University of Human Research Ethics Committee (HR2020-0337) and from the KSA Ministry of Education (4181827686). School principals will provide permission to conduct the study in individual schools. Individual consent/assent will be obtained from students and their parents, and teachers. Study findings will be disseminated via peer-review publications, reports and conferences.

Food and nutrition education in Australian primary schools: parents' views

Purpose

Primary schools provide continuous, intensive contact with large numbers of children starting from a young age, thus providing an appropriate setting for the promotion of healthy eating through food and nutrition education (FNE). This qualitative study explores the views of Australian primary school parents about FNE in primary schools.

Design/methodology/approach

In total, 19 parents of primary school children from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo. A total of three themes emerged: FNE topics currently taught in primary schools, essential food skills and knowledge for primary school children and the importance of FNE.

Findings

Most parents thought that FNE is as important as the core subjects of primary school. Parental support for FNE, which is delivered over a prolonged period, and expanded by hands-on content such as cooking and gardening classes was evident. Parents viewed these classes as likely to improve children's food-related knowledge and healthy eating behaviours. Parents expressed appreciation for schools' emphasis on food sustainability and its alignment with school policies and practices. Parents were keen to see more sustainability included in the curriculum.

Practical implications

These results may have implications for curriculum developers and schools, as the findings can assist the design of food and nutrition curricula for primary schools which can empower children as well as their families to make better food-related decisions.

Originality/value

Australian parents' views of FNE in primary schools have been under examined.

Assessment of high school learners' familiarity with nutrition education principles

BACKGROUND/OBJECTIVES

The objective of the study was to assess adolescent learners' nutritional knowledge to suggest early intervention strategies that address knowledge deficiency gaps that have a negative impact on personal health and productivity.

SUBJECTS/METHODS

A cross-sectional survey design was used in the study. One circuit was purposively selected from Pinetown District, KZN, South Africa. A representative sample of 108 learners was randomly selected from 7 of the 8 schools in the district to complete the investigator administered questionnaire between July and August 2017.

RESULTS

Although the majority of learners were familiar with the nutrition education principles, a large proportion lacked the knowledge of essential nutrition and were in support of the incorporation of various strategies to promote nutrition education. Friedman test revealed significant differences, χ² (3) = 192.4, p < 0.001, between the mean rank scores of familiarity to different nutrition principles. Relative to other principles, balanced diet and food groups were the most critical issues. The overall mean of 3.7 for learners' priority level on nutrition education principles indicated the learners' view that knowledge of all principles was necessary for the attainment of a healthy lifestyle.

CONCLUSIONS

Many learners were not familiar with nutrition education principles. Hence this paper becomes very critical as it communicates the information to the community and suggests various nutrition education intervention strategies that have to be put in place in the school system to impart the necessary knowledge and skills that promote a long-term healthy lifestyle for the learners.

An Insight Into the Involvement of Mothers of Low Socioeconomic Status in Scottish Primary School Health Education Activities

School-based health activities that involve parents are more likely to be effective for child health and well-being than activities without a parent component. However, such school-based interventions tend to recruit the most motivated parents, and limited evidence exists surrounding the involvement of hard-to-reach parents with low socioeconomic status (SES). Mothers remain responsible for the majority of family care; therefore, this study investigated mothers with low SES to establish the reasons and barriers to their involvement in school-based health activities and to propose strategies to increase their involvement in those activities. Interviews were conducted with mothers with low SES, who were typically not involved in school-based health activities (n = 16). An inductive-deductive approach to hierarchical analysis revealed that there are several barriers resulting in mothers being less involved, particularly due to issues surrounding the schools' Parent Councils and the exclusivity of school-based events. Efforts made by the school to promote health activities and involve parents in such activities were revealed, alongside recommendations to improve on these practices. The findings offer multiple ways in which future school-based health interventions can recruit and involve mothers with low SES.

Parental engagement in school-based health promotion and education

Purpose

Children’s health and life chances are affected by many factors, with parents and schools holding influential roles. Yet relatively little is known about parental engagement in school-based health education and specifically, from the perspectives of health and education professionals. The purpose of this paper is to examine professionals’ perspectives on parental engagement in school-based health education.

Design/methodology/approach

An exploratory qualitative study was conducted with ten health, education and local authority professionals from a socio-economically deprived area in England. Semi-structured interviews explored the role of professionals within the school health curricula, roles that parents played in school health, and barriers and enablers to parental engagement in school health education.

Findings

Reported barriers to engagement related to assumptions about parents’ own health behaviours, impacts of funding and inspection regimes, and protected time for health within the school curriculum. Enablers included designated parental support workers based in the school, positive role modelling by other parents, consultation and engagement with parents and a whole school approach to embedding health within the wider curriculum.

Practical implications

Findings from this study suggest the importance of building meaningful partnerships with parents to complement school health education and improve child health outcomes.

Originality/value

This paper addresses an important gap in the research on parental engagement in school-based health education from the perspectives of health and education professionals. Effective partnerships with parents are crucial to the success of school health education.

Exploring the perspectives of 10-, 11-, and 12-year-old primary school students on physical activity engagement-"'Cause you can't just be sitting at a desk all the time!"

BACKGROUND

Research indicates that 91% of Canadian children are not engaging in enough physical activity (PA) to achieve health benefits. Physical education (PE) classes have been identified as a way to improve child health by facilitating engagement in movement-based activities. The daily physical activity (DPA) initiative was created with similar intentions and requires that students participate in at least 20 min of PA daily via PE classes and/or during instructional time for other subjects. Despite recommendations that 150 min of exercise/play be incurred weekly through either avenue, nearly half of Canadian schools fail to achieve this goal. The disconnect between PA-related school policies and low reported participation rates suggests that additional research is warranted. The purpose of this study was to explore the perspectives of primary students regarding the facilitators, barriers, and recommendations for PA engagement at their schools.

METHODS

Researchers conducted nine group interviews with 53 children aged 10-12, representing six primary schools in Northwestern Ontario using a semi-structured interview format. Sessions were analysed using inductive content analysis.

RESULTS

Participants discussed several facilitators of PA including enjoying activities (alleviating boredom and participating with others), accomplishment (skill building and enhanced self-image), and benefits in the classroom (thinking clearly and enhanced readiness to learn). Barriers to PA participation included school rules and culture (PA/PE restrictions, heavy workload, and "no work, no PA"), personal struggles (physical challenges and varied skill levels), and technology (being addictive and a replacement for being active). Recommendations for enhancing engagement that were outlined by the children centred around PE and daily physical activity (increase opportunities and involve students in planning/delivery) and recess-based themes (decrease focus on safety and make equipment more available).

CONCLUSION

These student perspectives and related recommendations may be beneficial for administrators and teachers in similar contexts who are seeking to enhance PA engagement among students with the goal of improving child health.

School-based lifestyle education involving parents for reducing subjective psychosomatic symptoms in Japanese adolescents: study protocol for a cluster randomised controlled trial

INTRODUCTION

Severe subjective psychosomatic symptoms (SPS) in adolescents are a major public health concern, and lifestyle modification interventions for reducing SPS are important topics. Recently, we developed a school-based lifestyle education involving parents for reducing SPS of adolescents (SPRAT), an improved version of the programme from our previous study Programme for adolescent of lifestyle education in Kumamoto (PADOK). This study aimed to evaluate the effectiveness of SPRAT in reducing SPS among adolescents.

METHODS AND ANALYSIS

This is a 6-month, cluster randomised clinical trial with two intervention arms (SPRAT vs usual school education). The study population will be composed of middle school students (aged 12-14 years) with their parents/guardians in Japan. SPRAT is expected to be a more powerful programme than PADOK as it reinforces the role of parent participation. The primary endpoint will be the change from baseline SPS scores to those obtained after 6 months. Between-group differences will be analysed following the intention-to-treat principle. Crude and multivariate adjusted effects will be examined using a general linear mixed-effects model for continuous variables and a logistic regression model for dichotomous variables. The sample size required was determined based on the information needed to detect a difference in the primary outcome with a significance level of 5% and power of 80% under the assumptions of 40 students per cluster (assuming the same sample size for each cluster), an effect size of 0.3 and an intraclass correlation coefficient of 0.02. In total, participation by 28 schools (14 schools in each arm) (students: n=1120) will be needed.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethical Committee of Minami Kyushu University in 2017 (number 137). The findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000026715; Pre-results.

Copycat snacks: Can students differentiate between school and store snacks?

In 2014, the national Smart Snacks in School nutrition standards placed regulations on all snack foods sold in schools. Many food companies reformulated common snack food products for sale in schools, called "copycat snacks", which look similar to nutritionally different foods sold in stores. It is possible that these snacks create consumer confusion among students. The purpose of this study was to determine if middle school students could differentiate, in taste and appearance, between school (copycat) and store versions of common snacks. Seventy-six middle school students evaluated three different food products offered in schools: Froot Loops, Rice Krispy Treats, and Doritos. Students tasted snacks in a series of triangle tests for difference, one for each snack food, including school and store versions. Students were also presented with packages, school and store versions of the same products, and asked to determine the expected taste, purchase intentions, and perceived healthfulness. Students could determine taste differences between school and store Rice Krispy Treats yet could not differentiate between Froot Loop and Dorito varieties. Students rated store versions of all three snacks with greater expected taste, higher intention to purchase, and as less healthy. While it seems product confusion concerning copycat snacks may not be severe in this sample, snack food brands are still a prominent feature in schools. It is possible that these copycat snacks can confuse students' perceptions of healthy foods. Alternative packaging for school foods or reformation of store versions of snack foods may be viable solutions to this problem.

Trends in Attitudes and Practice Patterns of Physical Therapists in Addressing Childhood Obesity in Schools

PURPOSE

This study investigated trends in attitudes of school physical therapists about intervention for childhood obesity.

METHODS

A survey was developed to quantify attitudes. Two cases investigated the influence of attitudes on choices in treatment frequency. Factor analysis further delineated reasons for treatment frequency recommendations.

RESULTS

Attitudes did not change. Variability in responses decreased. Personal characteristics had evolving influence. In 2008, the perception of the PT's role in childhood obesity intervention had a greater influence on the choice to treat, but in 2015 the perception of the seriousness had a bigger effect on that decision.

DISCUSSION

Changing demographics of the therapists, increasing prevalence of obesity, and recent attention to the problem may have contributed to the trends.

CONCLUSION

There is no consensus as to the role of school physical therapy with intervention for obesity, but influential variables are emerging and practice patterns are evolving.

A Qualitative Phenomenological Exploration of Teachers' Experience With Nutrition Education

Background: Nutrition education delivered by classroom teachers has become a popular intervention designed to combat childhood obesity. However, few qualitative studies have explored nutrition education with teachers Purpose: The purpose of this study was to explore how elementary teachers describe their experience with nutrition education. Methods: A qualitative phenomenological approach was used. Semistructured interviews, observations, and document analysis were conducted with 10 teachers who delivered nutrition education in their classrooms. Inductive coding was used to determine invariant constituents, reduce constituents to categories, and cluster categories into themes. Reliability and validity were accomplished through intercoder agreement, audio recording, triangulation, bracketing, and member checking. Results: Results identified 5 core themes related to roles teachers play in nutrition education, the importance placed upon nutrition, motivation for supplementary activities, barriers, and a triadic relationship between students, teachers, and curriculum. Discussion: Findings reveal interactions within the nutrition education experience in which teachers balance barriers with their value of nutrition education and motivation to help students make healthy choices. Translation to Health Education Practice: Health educators should work with classroom teachers at the program design, implementation, and evaluation stages of curriculum development to better address needs and facilitate the delivery of high-quality nutrition education for students.

Parent and child perceptions of school-based obesity prevention in England: a qualitative study

BACKGROUND

Schools are key settings for childhood obesity prevention, and the location for many intervention studies. This qualitative study aims to explore parent and child experiences of the WAVES study obesity prevention intervention, in order to gain understanding of the mechanisms by which the intervention results in behaviour change, and provide context to support interpretation of the main trial results.

METHODS

Focus groups were held with 30 parents and 62 children (aged 6-7 years) from primary schools in the West Midlands, UK. Data analysis (conducted using NVivo 10) was guided by the Framework Approach.

RESULTS

Three over-arching themes were identified: 'Impact', 'Sustainability' and 'Responsibilities', under which sub-themes were determined. Participants were supportive of the school-based intervention. Parental involvement and the influential role of the teacher were seen as key ingredients for success in promoting consistent messages and empowering some parents to make positive behavioural changes at home. Parents recognised that whilst they held the primary responsibility for obesity prevention in their children, they faced a number of barriers to healthier lifestyles, and agreed that schools have an important role to play.

CONCLUSIONS

This study enabled us to better understand aspects of the WAVES study intervention programme that have the potential to initiate positive behaviour changes in families, and indicated that a combination of pathways influenced such changes. Pathways included: increasing capability through improving knowledge and skills of children and parents; increasing motivation through parental empowerment and role modelling; and the direct provision of opportunities to lead healthier lifestyles. Strategies to sustain behaviour changes, and the school role in supporting these, are important considerations.

[Health education in primary school: Alicante city (Spain) teachers' opinions]

OBJECTIVE

This study explores the opinions of primary school teachers about health activities carried out in schools in Alicante city (Spain).

METHODS

An exploratory study was conducted through qualitative content analysis. Three focus groups were conducted with 25 primary school teachers (14 women and 11 men) working in 14 public and 7 private schools in the city of Alicante. Participants were asked about the health activities carried on in their schools.

RESULTS

Teachers distinguished between health education activities promoted by the school and those included in external programmes promoted by public and private institutions. External programmes were considered as impositions, lacking continuity and chosen according to passing fads. Although teachers demonstrated a more positive attitude towards activities arising from their own initiative, they identified health education as a secondary task. Teachers considered that improving their own health education training and promoting the involvement of parents, health professionals and public institutions were the most appropriate ways to promote health education in the school.

CONCLUSION

Teachers showed a more positive opinion and greater commitment towards health activities that complement and facilitate their teaching tasks. Their didactic programme and opinion should be taken into account to maximise the efficiency of the health promotion and education activities promoted by external organisations.

Parent participation plays an important part in promoting physical activity

Although physical activity (PA) is an important and modifiable determinant of health, in Sweden only 15% of boys and 10% of girls aged 15 years old achieve the recommended levels of PA 7 days per week. Adolescents' PA levels are associated with social influence exerted by parents, friends, and teachers. The purpose of this study was to describe parents' experiences of being a part of their adolescents' empowerment-inspired PA intervention. A qualitative interview study was performed at a school in the northern part of Sweden. A total of 10 parents were interviewed, and the collected data were analyzed with qualitative content analysis. Three subthemes were combined into one main theme, demonstrating that parents are one important part of a successful PA intervention. The life of an adolescent has many options and demands that make it difficult to prioritize PA. Although parents felt that they were important in supporting their adolescent, a successful PA intervention must have multiple components. Moreover, the parents noted that the intervention had a positive effect upon not only their adolescents', but also their own PA. Interventions aimed at promoting PA among adolescents should include measures to stimulate parent participation, have an empowerment approach, and preferably be school-based.