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Lareyre O, Cousson-Gélie F, Pereira B, Stoebner-Delbarre A, Lambert C, Gourlan M. Effect of a peer-led prevention program (P2P) on smoking in vocational high school students: Results from a two-school-year cluster-randomized trial. Addiction 2024; 119:1616-1628. [PMID: 38780044 DOI: 10.1111/add.16528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/17/2024] [Indexed: 05/25/2024]
Abstract
AIMS The aim of this work was to measure the impact of P2P (i.e. peer-to-peer), a peer-led smoking prevention intervention, on daily smoking prevalence of adolescents over 2 school years. DESIGN A cluster-randomized controlled trial was performed over a 16-month follow-up (trial status: closed to follow-up). P2P was implemented 1-3 and 13-15 months after baseline. Assessments took place at baseline and 4, 10 and 16 months after baseline. The research team, assessors and adolescents were blinded to the study-arm assignment only at baseline. SETTING Fifteen vocational high schools in France were randomized into two clusters, using a 1:1 allocation ratio per French department (n intervention = 7, n control = 8). PARTICIPANTS Participants comprised a sample of 2010 students in year 11 (i.e. 15-16 years) in vocational high schools. A total of 437 students could not be assessed at baseline (absent or left school), yielding a total sample of 1573 students (n intervention = 749, n control = 824). INTERVENTION AND COMPARATOR The P2P programme trained voluntary students to become peer educators and design smoking prevention actions for their schoolmates in the intervention group (n = 945 students), compared with a passive control group (n = 1065 students). MEASUREMENTS The primary outcome was change from baseline in the prevalence of self-reported daily smoking (i.e. at least one cigarette per day) at 16 months. FINDINGS The 'time × group' interaction indicated that, compared with the control group, the intervention group had statistically significantly fewer daily smokers after 16 months [odds ratio (OR) = 0.33, 95% confidence interval (CI) = 0.20, 0.53]. Similarly, compared with the control group, the intervention group had statistically significantly fewer daily smokers after 4 months (OR = 0.50, 95% CI = 0.30, 0.82) and 10 months (OR = 0.60, 95% CI = 0.37, 0.98). No adverse events of P2P2 were reported. CONCLUSIONS A cluster-randomized trial found evidence that the peer-led P2P (peer-to-peer) smoking prevention intervention reduced the uptake of daily smoking among high school students in France over 16 months.
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Affiliation(s)
- Olivier Lareyre
- Epidaure-Prevention Department of the Montpellier Cancer Institute, Montpellier Cancer Institute, Montpellier, France
- Univ. Paul Valéry Montpellier 3, EPSYLON UR 4556, F34000, Montpellier, France
| | - Florence Cousson-Gélie
- Epidaure-Prevention Department of the Montpellier Cancer Institute, Montpellier Cancer Institute, Montpellier, France
- Univ. Paul Valéry Montpellier 3, EPSYLON UR 4556, F34000, Montpellier, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, Biostatistics Unit, DRCI, Clermont-Ferrand, France
| | - Anne Stoebner-Delbarre
- Onco-Addiction and Patient Education Unit-Supportive Care Department, Montpellier Cancer Institute, Montpellier, France
| | - Céline Lambert
- CHU Clermont-Ferrand, Biostatistics Unit, DRCI, Clermont-Ferrand, France
| | - Mathieu Gourlan
- Epidaure-Prevention Department of the Montpellier Cancer Institute, Montpellier Cancer Institute, Montpellier, France
- Univ. Paul Valéry Montpellier 3, EPSYLON UR 4556, F34000, Montpellier, France
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Kjeld SG, Homberg T, Andersen S. Relationship between smoking and mental health in educational settings with high smoking rates: a cohort study among Danish youth. Scand J Public Health 2024:14034948241227305. [PMID: 38342989 DOI: 10.1177/14034948241227305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
BACKGROUND Smoking and poor mental health in youth represent important public health priorities. This study aimed to (i) compare tobacco-related behaviors and mental health in two educational settings with high smoking rates: vocational education and training (VET) schools and preparatory basic education (PBE) schools, and (ii) examine associations between smoking at school start and mental health 5 months later. METHODS Data were obtained from baseline (N = 1843) and follow-up (N = 1039) assessments conducted as part of a school-based trial in two rounds (baseline in August 2018 and August 2019). Students' characteristics were presented by adjusted prevalences. Logistic regression analyses assessed associations between smoking and measures of mental health: school-related well-being, overall loneliness, and stress. RESULTS More PBE students than VET students reported daily smoking (40% vs. 27%), nicotine dependence, perceived benefits of smoking (e.g., stress reduction: 41% vs. 33%), low smoking-related self-efficacy (e.g., ability to resist smoking if offered by a friend: 20% vs. 32%), school-related loneliness, and low school connectedness (25% vs. 11%). Daily smokers at VET and PBE schools had lower odds of school-related loneliness (AOR = 0.51, 95% CI: 0.35-0.74) and higher odds of stress (AOR = 2.75, 95% CI: 2.00-3.80). Smoking was associated with better classmate relations in VET schools but not in PBE schools. CONCLUSIONS Our study suggested that students in PBE schools constitute a more vulnerable group in terms of smoking and mental health compared with students in VET schools. Smoking seemed to prevent loneliness in school but was associated with heightened stress levels.
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Affiliation(s)
- Simone G Kjeld
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Kjeld SG, Thygesen LC, Danielsen D, Jensen MP, Krølner RF, Pisinger C, Andersen S. Do school-based smoking preventive interventions have unintended effects? Post hoc analysis of the Focus cluster randomised controlled trial. BMJ Open 2024; 14:e070176. [PMID: 38191253 PMCID: PMC10806711 DOI: 10.1136/bmjopen-2022-070176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting. DESIGN Cluster randomised controlled trial stratified by school type with 5 months follow-up. SETTING AND PARTICIPANTS Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491). INTERVENTIONS The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support. OUTCOMES Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers. RESULTS We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40). CONCLUSIONS Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers. TRIAL REGISTRATION NUMBER ISRCTN16455577.
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Affiliation(s)
- Simone G Kjeld
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Lau C Thygesen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Dina Danielsen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Marie P Jensen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Rikke F Krølner
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Charlotta Pisinger
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
- Center for Clinical Research and Prevention, Frederiksberg University Hospital, Frederiksberg, Denmark
- Tryg Foundation, Virum, Denmark
| | - Susan Andersen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
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Kjeld SG, Thygesen LC, Danielsen D, Jakobsen GS, Jensen MP, Holmberg T, Bast LS, Lund L, Pisinger C, Andersen S. Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial. BMC Public Health 2023; 23:419. [PMID: 36864450 PMCID: PMC9979485 DOI: 10.1186/s12889-023-15331-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking. METHODS A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. RESULTS Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. CONCLUSION This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. TRIAL REGISTRATION https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.
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Affiliation(s)
- Simone G Kjeld
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark.
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Dina Danielsen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Gitte S Jakobsen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Marie P Jensen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Lotus S Bast
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Lisbeth Lund
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Charlotta Pisinger
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Copenhagen, Denmark.,Faculty of Health Sciences, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Danish Heart Foundation, Copenhagen, Denmark
| | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
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Zhao Y, Di X, Li S, Zeng X, Wang X, Nan Y, Xiao L, Koplan J, Chen Z, Liu S. Prevalence, frequency, intensity, and location of cigarette use among adolescents in China from 2013-14 to 2019: Findings from two repeated cross-sectional studies. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 27:100549. [PMID: 35923777 PMCID: PMC9340429 DOI: 10.1016/j.lanwpc.2022.100549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The burden of disease caused by tobacco use is a grave public health concern in China. Preventing smoking initiation among adolescents will lower the prevalence of adult tobacco use later. Surveillance of tobacco use among adolescents helps set priorities in developing tobacco control policies. We aim to ascertain the prevalence and differences of cigarette use across sex, grade, and region among middle and high school students in 2019 and associated changes from 2013-14 to 2019 among middle school students. METHODS Using a multistage stratified cluster-randomized sampling design with national and provincial representativeness, we conducted two school-based cross-sectional surveys in 2013-14 and in 2019. A total of 155 117 middle school students in grades 7-9 in 2013-14 and 288 192 middle and high school students in grades 7-12 in 2019 were interviewed. Self-reported experimental and current (past 30-day) cigarette use among middle school and high school students; frequent use (≥20 days in the past 30 days) and intensity (>20 cigarettes per day) of smoking among current cigarette users; and location of smoking among current cigarette users were investigated. All estimates were weighted based on the complex sampling design. FINDINGS The 2013-14 survey (overall response rate: 98.1%) included 155 117 middle school students (47.1% girl). The 2019 survey (overall response rate: 98.7%) included 147 270 middle school students (46.5% girl), 106 432 academic high school students (50.8% girl) and 34 490 vocational high school students (43.8% girl). In 2019, the prevalence rate of experimental and current cigarette use was 12.9% and 3.9% for middle school students, 21.6% and 5.6% for academic high school students, and 30.3% and 14.7% for vocational high school students, respectively, with large sex and regional differences. The prevalences of smoking on 20 or more days and daily cigarette use in the past 30 days were higher in vocational high school (5.9%, 4.1%) than in academic high school (1.8%, 1.2%) and middle school (0.7%, 0.5%), and higher among boys than girls. The proportions of current cigarette users smoking more than 20 cigarettes per day in the past 30 days for girls were higher than for boys in academic high school. Students usually smoke at school and at home. Boys were more likely to use cigarettes in an internet cafe, while girls often smoked at social venues. From 2013-14 to 2019, the prevalences of experimental and current cigarette use declined by 5.0% and 2.0% (percentage points), respectively, among middle school students but increased by 1.4% and 0.5% (percentage points) among rural girls. Among current cigarette users in middle school students, the proportions of heavy cigarette use (>20 cigarettes per day) have increased by 1.8 percentage points, mainly among boys, by 2.2% (percentage points). INTERPRETATION From 2013-14 to 2019, the prevalences of experimental and current cigarette use among middle school students decreased overall but increased among rural girls, while the intensity of cigarette use rose among boys. Cigarette use among Chinese adolescents differs across sex and regions, with higher rates among boys, in rural areas, and in the Western region (low socioeconomic status). Smoking is much more prevalent in vocational high schools than the other settings. Effective targeted tobacco control interventions among adolescents are urgently needed in China. FUNDING Dr. Zhuo Chen is supported by National Natural Science Foundation (Grant#: 72174098) through the University of Nottingham Ningbo China.
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Affiliation(s)
- Yan Zhao
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
- Department of Public Health, School of Public Health, Inner Mongolia Medical University, Huhehot, Inner Mongolia 010110, China
| | - Xinbo Di
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
| | - Sixuan Li
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
- Ningbo Municipal Center for Disease Control and Prevention, 237# Yongfeng Road, Haishu District, Ningbo, Zhejiang Province 315010, China
| | - Xinying Zeng
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
| | - Xiaofeng Wang
- Information Center, Chinese Center for Disease Control and Prevention, 155# Changbei Road, Changping District, Beijing 102206, China
| | - Yi Nan
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
| | - Lin Xiao
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
| | - Jeffrey Koplan
- Emory Global Health Institute, Emory University, Atlanta 30322 Georgia, USA
| | - Zhuo Chen
- College of Public Health, University of Georgia, Athens 30602 Georgia, USA
- School of Economics, University of Nottingham Ningbo China 315100 Ningbo, Zhejiang Province, China
| | - Shiwei Liu
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing 100050, China
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Zeng X, Di X, Liu S, Xie H, Meng Z, Xiao L. Smoking Behavior Among Secondary School Students — China, 2021. China CDC Wkly 2022; 4:441-447. [PMID: 35686047 PMCID: PMC9167609 DOI: 10.46234/ccdcw2022.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Xinying Zeng
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xinbo Di
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shiwei Liu
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Huiyu Xie
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zida Meng
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lin Xiao
- Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
- Lin Xiao,
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Hansen SK, Holm LAB, Niclasen BVL, Schnohr C. The effect of structural and functional social relations on smoking among adolescents - data from HBSC Greenland 2018. Int J Circumpolar Health 2020; 79:1773196. [PMID: 32552536 PMCID: PMC7480422 DOI: 10.1080/22423982.2020.1773196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The prevalence of adolescent smoking in Greenland is relatively high and remains an important topic to study. The present study reports the prevalence of smoking among Greenlandic adolescents in 2018 and the association between smoking and social relations. The study was based on HBSC Greenland 2018, using a theoretical framework proposed by Due and colleagues, which divides social relations into structural and functional relations. The study showed a statistically significant gender difference in smoking, as 11.4% of the girls reported to smoke compared to 7.9% of the boys. The smoking prevalence increased significantly with age, and differences were also found for a place of residence, as the smoking prevalence was higher in towns and settlements compared to Nuuk. The adolescent smoking prevalence was higher when living in a home with one adult or in a foster family, school home or orphanage, versus living in home with at least two adults. No significant associations were found between adolescent smoking and functional relations. The results are beneficial to consider when applying new interventions to prevent adolescent smoking initiation in Greenland.
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Affiliation(s)
- Stina Kaarde Hansen
- Section of Social Medicine, Department of Public Health, University of Copenhagen , Copenhagen, Denmark
| | | | | | - Christina Schnohr
- Section of Social Medicine, Department of Public Health, University of Copenhagen , Copenhagen, Denmark
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Hosseinkhani Z, Hassanabadi HR, Parsaeian M, Nedjat S, Foroozanfar Z. The role of mental health, academic stress, academic achievement, and physical activity on self-rated health among adolescents in Iran: A multilevel analysis. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2020; 9:182. [PMID: 33015205 PMCID: PMC7497124 DOI: 10.4103/jehp.jehp_161_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 05/03/2023]
Abstract
BACKGROUND Health promotion of adolescents requires appropriate evidences of its determinants. The aim of this study was to investigate predictors of self-rated health (SRH) among adolescents in Qazvin, Iran. MATERIALS AND METHODS In this descriptive cross-sectional study, with a multistage sampling method, we recruited 1740 adolescents aged 12-19 years from 53 schools in Qazvin, Iran (2018). We used the Strengths and Difficulties Questionnaire and Adolescents' Academic Stress Questionnaire for data collection. The analysis was conducted using a multilevel logistic regression model. Gender, educational period, and socioeconomic status were considered as confounders. RESULTS Almost 21% of the adolescents reported their SRH suboptimal. Suboptimal SRH was higher in girls and older adolescents. Mental health disorders and academic stress had a positive association with SRH. However, this association was negative for academic achievement and physical activity. The interaction between mental health disorders and academic stress with SRH had a significant association in a crud regression model. CONCLUSION Mental health, academic stress, academic achievement, and physical activity were important predictors for SRH. Interventions that focus on promoting mental health, academic stress, academic achievement, and physical activity such as physical activity for 1 h and each day for 3 days per week can improve SRH in adolescents. Hence, policymakers should pay more attention to this issue in health promotion programs of adolescents.
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Affiliation(s)
- Zahra Hosseinkhani
- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin, University of Medical Sciences, Qazvin, Iran
| | | | - Mahboubeh Parsaeian
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, Knowledge Utilization Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Address for correspondence: Dr. Saharnaz Nedjat, Department of Epidemiology .and Biostatistics, Knowledge Utilization Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. E-mail:
| | - Zohre Foroozanfar
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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