Systematic review of reviews of observational studies of school-level effects on sexual health, violence and substance use

Are educational aspirations associated with susceptibility to smoking, e-cigarette use, and smokeless tobacco use in adolescence?

The early socio-economic differences in smoking build on the interplay between individual-, family-, peer-, and school-related factors. The present study aimed to add knowledge to this by examining susceptibility to smoking (S-SM), electronic cigarette (e-cigarette) use (S-EC), and smokeless tobacco (snus) use (S-SN) by educational aspirations in a country with advanced tobacco control policies. National cross-sectional School Health Promotion study survey was conducted among 8.-9. grade students (av. 15-year-olds) in 2017 with no prior smoking (n = 47 589), e-cigarette use (n = 49 382), or snus use (n = 53 335). Gender-stratified, age-adjusted multilevel logistic regression analyses with S-SM, S-EC, and S-SN were considered as outcomes and student- and school-level (aggregated) factors were considered as independent variables. The highest prevalence was observed for S-EC (girls 29%, boys 35%), followed by S-SM (16%, 15%) and S-SN (10%, 16%). Compared to those planning for general upper secondary education, S-SM was the highest for those without educational aspirations (OR = 1.20, 95% CI = 1.04-1.40), S-EC for those planning for vocational education [1.15 (1.05-1.25)], and S-SN for those planning for extra year/discontinuation [1.65 (1.04-2.60)] among girls. Among boys, both S-SM [1.37 (1.23-1.52)] and S-EC [1.19 (1.09-1.29)] were the highest among those planning for vocational education, with no clear associations with S-SN. Current other tobacco/e-cigarette use [OR range 1.27-8.87], positive attitude towards product use in one's age group [3.55-6.63], and liking school [0.58-0.68] consistently associated with susceptibility. Students not planning for academically oriented education had higher susceptibility to different nicotine products. High S-EC warrants monitoring to strengthen policy evaluation and prevention.

Problematic familial alcohol use and adolescent outcomes: Do associations differ by parental education?

Aim: To investigate the associations between problematic familial alcohol use and adolescent subjective health, binge drinking, relationships with parents, school performance, and future orientation, and to study whether these associations differ in relation to parental education. Methods: Cross-sectional data from the Stockholm School Survey (SSS) collected among students in the 9th and 11th grades in 2018 and in 2020 were used (n = 19,415). Subjective health, parent-youth relationships, and school performance were coded as continuous variables; binge drinking and future orientation were coded as binary variables. Familial drinking included three categories: problematic; don't know/missing; and not problematic. Parental university education distinguished between adolescents with two, one, or no university-educated parent(s). Control variables included gender, grade, family structure, migration background, parental unemployment, and survey year. Linear and binary logistic regression analyses were performed. Results: Problematic familial alcohol use was associated with worsened subjective health, a higher likelihood of engaging in binge drinking, worse relationships with parents, and a higher likelihood of having a pessimistic future orientation, even when adjusting for all control variables. Having less than two university-educated parents was associated with a higher likelihood of reporting problematic familial alcohol use. Parental university education moderated the association between problematic familial alcohol use and binge drinking as this relationship was stronger for adolescents with no and one university-educated parent(s). Conclusions: Adolescents with problematic familial alcohol use fared worse with regards to all studied outcomes, except for school performance. Parental university education only moderated the association between problematic familial alcohol use and binge drinking. However, since problematic familial alcohol use was more common among adolescents with less than two university-educated parents, we argue that at the group level, this category may be more negatively affected by alcohol abuse in the family. Policy interventions could benefit from having a socioeconomic perspective on how children are affected by alcohol's harms to others.

School collective efficacy and gambling: A multilevel study of 11th grade students in Stockholm

The aim of the present study was to investigate variations between schools when it comes to gambling and risk gambling, and, in particular, to analyse the links between school collective efficacy and student gambling and risk gambling. The data consists of official register information on schools as well as survey data collected in 2016 among 1,061 teachers and 5,191 students in 46 Stockholm upper secondary schools. School collective efficacy was operationalized on the basis of teacher responses, which were aggregated to the school level. Gambling and risk gambling were based on students' self-reports. Two-level binary logistic regression analyses were performed. The results show that there is between-school variation in gambling and in all the study's indicators of risk gambling. Both gambling and risk gambling were more commonly reported by students attending schools with weak collective efficacy, even when adjusting for student- and school-level sociodemographic characteristics. The findings suggest that conditions at school may counteract students' engagement in gambling and risk gambling.

The Effectiveness and Acceptability of Comprehensive and Multicomponent School Health Services: A Systematic Review

PURPOSE

Comprehensive school-based health services were reviewed as part of preparing World Health Organization guidelines.

METHODS

Six databases were searched for controlled trials with schoolchildren aged 5-19 years, involving school-linked health services incorporating 4 of 7 health areas.

RESULTS

Seventeen quasi-experimental studies conducted in high-income countries found school health services associated with reductions in suicide planning (male: 7.1% vs. 7.7%, p < .01), hospitalization (relative risks 3.403, 95% confidence interval [CI] 1.536 to 8.473, p < .05), emergency department visits (odds ratio .85, 95% CI .75 to .95, p = .006), school absence (odds ratio .78, 95% CI .69 to .87, p < .0001), carrying weapons (male: 16.1% vs. 25.1%, p < .01), fighting (male: 32.6% vs. 43.1%, p < .01), sexual activity (53.5% vs. 60.5%, p < .05), drinking alcohol (60.1% vs. 70.5%, p < .001), using drugs (28.0% vs. 38.3%, p < .001), and physical activity (female: 57.4% vs. 50.4%, p < .01). They can be cost-saving, were also associated with smoking and less contraceptive use, and had no effect on depression prevalence. Acceptability/satisfaction was good. The certainty of evidence was low to moderate. Heterogeneity was high for some outcomes.

CONCLUSIONS

Results suggest moderate desirable and trivial undesirable effects of school health services in high-income countries. This article compiles evidence on effectiveness, cost-effectiveness, and acceptability into one review, enabling decision-makers to consider all essential factors.

Problematic familial alcohol use and heavy episodic drinking among upper secondary students: a moderator analysis of teacher-rated school ethos

Objective

Building on findings reported in a previous publication, the objective of this study is to explore if teacher-rated indicators of school ethos modify the association between problematic familial alcohol use and heavy episodic drinking among upper secondary students. Data were based on combined information from two separate surveys conducted in 2016 among 4709 students and 1061 teachers in 46 Stockholm upper secondary schools, with linked school-level information from administrative registers. Multilevel binary logistic regression analyses were performed.

Results

Problematic familial alcohol use was associated with an increased likelihood of heavy episodic drinking among upper secondary students (OR 1.36, 95% CI 1.12–1.65). Cross-level interactions revealed that the association was weaker among students attending schools with higher levels of teacher-rated ethos. This was true for overall school ethos (OR 0.79, 95% CI 0.65–0.97) and for four of five studied sub-dimensions of ethos: staff stability (OR 0.78, 95% CI 0.65–0.95); teacher morale (OR 0.79, 95% CI 0.65–0.97); student focus (OR 0.80, 95% CI 0.65–0.97); and academic atmosphere (OR 0.79, 95% CI 0.65–0.96). The sub-dimension “structure and order for dealing with unwanted behaviour” did however not moderate the association between problematic familial alcohol use and heavy episodic drinking (OR 0.95, 95% CI 0.77–1.18).

Teacher-Rated School Leadership and Adolescent Gambling: A Study of Upper Secondary Schools in Stockholm, Sweden

So-called “effective schools” are characterised by properties such as a strong and purposeful school leadership and a favourable school ethos. In a previous study we showed that a school’s degree of teacher-rated ethos was inversely associated with student gambling and risk gambling. Building on these findings, the current study aims to examine the associations that teachers’ ratings of the school leadership share with gambling and risk gambling among students in the second grade of upper secondary school in Stockholm (age 17–18 years). Data were drawn from the Stockholm School Survey and the Stockholm Teacher Survey with information from 5191 students and 1061 teachers in 46 upper secondary schools. School-level information from administrative registers was also linked to the data. The statistical method was two-level binary logistic regression analysis. Teachers’ average ratings of the school leadership were inversely associated with both gambling (OR 0.96, 95% CI 0.93–0.998, p = 0.039) and risk gambling (OR 0.94, 95% CI 0.89–0.99, p = 0.031) among upper secondary students, whilst adjusting for sociodemographic characteristics at the student and the school level. The findings lend further support to the hypothesis that characteristics of effective schools may reduce students’ inclination to engage in gambling and risk gambling behaviours.

Systematic review of reviews of symptoms and signs of COVID-19 in children and adolescents

OBJECTIVE

To undertake a systematic review of reviews of the prevalence of symptoms and signs of COVID-19 in those aged under 20 years.

DESIGN

Narrative systematic review of reviews. PubMed, medRxiv, Europe PMC and COVID-19 Living Evidence Database were searched on 9 October 2020.

SETTING

All settings, including hospitalised and community settings.

PATIENTS

Children and young people (CYP) under age 20 years with laboratory-proven COVID-19.

STUDY REVIEW, DATA EXTRACTION AND QUALITY

Potentially eligible articles were reviewed on title and abstract by one reviewer. Quality was assessed using the modified AMSTARS criteria and data were extracted from included studies by two reviewers.

MAIN OUTCOME MEASURES

Prevalence of symptoms and signs of COVID-19.

RESULTS

1325 studies were identified and 18 reviews were included. Eight were high quality, 7 medium and 3 low quality. All reviews were dominated by studies of hospitalised children. The proportion of asymptomatic CYP ranged from 14.6% to 42%. Fever and cough were the the most common symptoms; proportions with fever ranged from 46% to 64.2% and with cough from 32% to 55.9%. All other symptoms or signs including rhinorrhoea, sore throat, headache, fatigue/myalgia and gastrointestinal symptoms including diarrhoea and vomiting were infrequent, occurring in less than 10%-20%.

CONCLUSIONS

Fever and cough are the most common symptoms in CYP with COVID-19, with other symptoms infrequent. Further research on symptoms in community samples are needed to inform pragmatic identification and testing programmes for CYP.

Reframing school-based restorative justice as a structural population health intervention

School-based restorative justice has gained national prominence as an effective approach to interrupting the school-to-prison pipeline. Remarkably, despite its simultaneous positive association with academic success, school safety, and school connectedness, most scholars and practitioners do not associate restorative justice with health. Using ecosocial theory, we conceptualize school-based restorative justice as a structural population health intervention. Our findings indicate that students attending schools using restorative justice have lower odds of missing school due to adverse health and better academic outcomes compared to students who do not. Restorative justice shows promise as a structural intervention that can contribute to improving population health.

Poor Relationships and Physical Violence at School Are Associated With More Forms of Psychological Violence Among Brazilian Teachers: A Cross-Sectional Study

Our purpose was to identify individual and work-related factors that are associated with psychological violence (PV) and are related to a higher number of PV forms among teachers. This cross-sectional study included 789 elementary and high school teachers in a municipality in southern Brazil. Data were obtained through interviews and a self-administered questionnaire. PV was characterized by reports of insults from students, humiliation by colleagues or teachers, and threats in the 12 months preceding the study. Factors associated with the number of PV forms were also investigated. Poisson regression models were used for the analyses. More than half (64.1%) of the teachers reported at least one event of PV, 38.3% reported only one form, 21.5% reported two forms, and 4.3% reported all three surveyed forms. After adjustments, poor relationships with superiors or students and having suffered physical violence at school remained associated with at least one PV episode. The same variables were associated with the number of forms of PV, as were age (inverse relationship) and violence outside of school. The higher the number of aggregated factors, the more estimated forms of PV, particularly among the younger teachers. These results highlight the importance of adopting strategies that promote a nonviolent and safe school environment for teachers, which will in turn improve work conditions, the quality of education, and teachers' health.

Effects of screentime on the health and well-being of children and adolescents: a systematic review of reviews

OBJECTIVES

To systematically examine the evidence of harms and benefits relating to time spent on screens for children and young people's (CYP) health and well-being, to inform policy.

METHODS

Systematic review of reviews undertaken to answer the question 'What is the evidence for health and well-being effects of screentime in children and adolescents (CYP)?' Electronic databases were searched for systematic reviews in February 2018. Eligible reviews reported associations between time on screens (screentime; any type) and any health/well-being outcome in CYP. Quality of reviews was assessed and strength of evidence across reviews evaluated.

RESULTS

13 reviews were identified (1 high quality, 9 medium and 3 low quality). 6 addressed body composition; 3 diet/energy intake; 7 mental health; 4 cardiovascular risk; 4 for fitness; 3 for sleep; 1 pain; 1 asthma. We found moderately strong evidence for associations between screentime and greater obesity/adiposity and higher depressive symptoms; moderate evidence for an association between screentime and higher energy intake, less healthy diet quality and poorer quality of life. There was weak evidence for associations of screentime with behaviour problems, anxiety, hyperactivity and inattention, poorer self-esteem, poorer well-being and poorer psychosocial health, metabolic syndrome, poorer cardiorespiratory fitness, poorer cognitive development and lower educational attainments and poor sleep outcomes. There was no or insufficient evidence for an association of screentime with eating disorders or suicidal ideation, individual cardiovascular risk factors, asthma prevalence or pain. Evidence for threshold effects was weak. We found weak evidence that small amounts of daily screen use is not harmful and may have some benefits.

CONCLUSIONS

There is evidence that higher levels of screentime is associated with a variety of health harms for CYP, with evidence strongest for adiposity, unhealthy diet, depressive symptoms and quality of life. Evidence to guide policy on safe CYP screentime exposure is limited.

PROSPERO REGISTRATION NUMBER

CRD42018089483.

Assessment of Exposure to High-Performing Schools and Risk of Adolescent Substance Use: A Natural Experiment

IMPORTANCE

Although school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown.

OBJECTIVE

To test whether exposure to high-performing schools is associated with risky adolescent health behaviors.

DESIGN, SETTING, AND PARTICIPANTS

This natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018.

EXPOSURES

Schools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades).

MAIN OUTCOMES AND MEASURES

Primary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students' social networks) were also examined.

RESULTS

Among the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P < .05). Stratified analyses suggest that among boys, intervention participants had significantly lower marijuana use (mean misuse score, 0.43 vs 0.88; difference, -0.45; 95% CI, -0.78 to -0.13) and alcohol misuse (mean misuse score, 0.52 vs 0.97; difference, -0.44; 95% CI, -0.80 to -0.09) scores compared with control participants, whereas no significant health outcomes were noted for girls.

CONCLUSIONS AND RELEVANCE

This natural experiment provides evidence that school environments can improve risky behaviors for low-income minority adolescents.