Sustainability of outdoor school ground smoking bans at secondary schools: a mixed-method study

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study

Implementing comprehensive health promotion programs in the school setting can be challenging, as schools can be considered complex adaptive systems. As a first step towards understanding what works in improving implementation for which schools and under which conditions, this study aimed to examine the degree of implementation of health promoting school (HPS) programs, in terms of five dimensions of fidelity (adherence, dose, participant responsiveness, quality of delivery and program differentiation), and the dimensions of adaptation and integration. The HPS Implementation Questionnaire was distributed among ± 2400 primary, secondary, secondary vocational and special needs schools in the Netherlands. Employees of 535 schools (22.3%) filled out the questionnaire. Data were analysed by descriptive statistics and ANOVA tests. The average degree of implementation was 2.55 (SD = 0.58, range = 0.68-3.90; scaled 0-4). The lowest scores were achieved for participant responsiveness and adherence, and the highest for integration and adaptation. Schools that identified as HPS reported significantly higher overall degree of implementation, adherence, dose, participant responsiveness, program differentiation and adaptation than schools that didn't. Primary schools achieved a significantly higher degree of implementation, dose, participant responsiveness, quality of delivery and integration than other school types. In conclusion, many schools work on student health and well-being to some extent, but the vast majority have much room for improvement. Higher implementation scores for schools that identified as HPS underline the value of HPS programs. A broader perspective on health and more insight into conditions for effectiveness and implementation in secondary and secondary vocational schools are needed.

Measuring Implementation of Health Promoting School (HPS) Programs: Development and Psychometric Evaluation of the HPS Implementation Questionnaire

BACKGROUND

Implementation of Health Promoting School (HPS) programs can be challenging due to the dynamic school context. Navigating between program fidelity and adaptation, as well as integrating the program, is essential for successful implementation, and consequently, for program effects. As part of an evaluation study in the Netherlands, this study aimed to develop a measurement instrument that differentiates schools according to fidelity, adaptation, and integration of HPS implementation.

METHODS

This study presents the development and psychometric evaluation of the 28-item HPS Implementation Questionnaire, covering 7 dimensions: adherence, dose, participant responsiveness, quality of delivery, program differentiation, adaptation, and integration. The questionnaire, to be filled out by school employees, was developed for primary, secondary, secondary vocational, and special needs education, in close collaboration with experts (n = 54) in school health promotion.

RESULTS

Semi-structured interviews aimed at dimension clarification resulted in a list of 58 items. Items were revised, combined, and/or removed based on quantitative and qualitative feedback by the evaluation study's Community of Practice, 2-round expert consultation, and pre-tests. Psychometric evaluation (n = 535 schools), consisting of calculating Cronbach's α and confirmatory factor analysis (CFA), confirmed internal consistency (α > .72) and the 7-dimension framework.

CONCLUSION

The brief yet comprehensive HPS Implementation Questionnaire offers possibilities for research into HPS implementation in various educational sectors and contexts, as well as self-monitoring by individual schools. This study provides first evidence for internal consistency and validity of the questionnaire.

A Pilot Randomised Controlled Trial to Increase the Sustainment of an Indoor-Outdoor-Free-Play Program in Early Childhood Education and Care Services: A Study Protocol for the Sustaining Play, Sustaining Health (SPSH) Trial

Early Childhood Education and Care (ECEC) settings are important environments to support children's physical activity (PA). In 2021, COVID-19 regulations recommended the provision of indoor-outdoor free-play programs in ECEC settings to reduce the transmission of COVID-19, resulting in an increased uptake of this practice. As the context has since changed, research suggests that ECEC services could cease the implementation of these practices. Therefore, this pilot randomised controlled trial (RCT) aims to examine the feasibility, acceptability, and impact of a sustainment strategy to ensure the ongoing implementation (sustainment) of ECEC-delivered indoor-outdoor free-play programs. Twenty ECEC services located in New South Wales, Australia that have implemented indoor-outdoor free-play programs since the release of COVID-19 guidelines will be recruited. The services will be randomly allocated either the sustainment strategy or usual care. The "Sustaining Play, Sustaining Health" program consists of eight strategies, developed to address key barriers against and facilitators of sustainment informed by the Integrated Sustainability Framework. The outcomes will be assessed via internal project records, staff surveys, and a self-reported measure of free play. This study will provide important data to support the performance of a fully powered trial within Australian ECEC settings and to inform the development of future sustainment strategies.

A systematic review of school health policy measurement tools: implementation determinants and outcomes

BACKGROUND

Governments in some countries or states/provinces mandate school-based policies intended to improve the health and well-being of primary and secondary students and in some cases the health of school staff. Examples include mandating a minimum time spent per week in programmed physical activity, mandating provision of healthy foods and limiting fat content of school meals, and banning tobacco products or use on school campuses. Although school health researchers have studied whether schools, districts, or states/provinces are meeting requirements, it is unclear to what extent implementation processes and determinants are assessed. The purposes of the present systematic review of quantitative measures of school policy implementation were to (1) identify quantitative school health policy measurement tools developed to measure implementation at the school, district, or state/provincial levels; (2) describe the policy implementation outcomes and determinants assessed and identify the trends in measurement; and (3) assess pragmatic and psychometric properties of identified implementation measures to understand their quality and suitability for broader application.

METHODS

Peer-reviewed journal articles published 1995-2020 were included if they (1) had multiple-item quantitative measures of school policy implementation and (2) addressed overall wellness, tobacco, physical activity, nutrition, obesity prevention, or mental health/bullying/social-emotional learning. The final sample comprised 86 measurement tools from 67 peer-review articles. We extracted study characteristics, such as psychometric and pragmatic measure properties, from included articles based on three frameworks: (1) Implementation Outcomes Framework, (2) Consolidated Framework for Implementation Research, and (3) Policy Implementation Determinants Framework.

RESULTS

Most implementation tools were developed to measure overall wellness policies which combined multiple policy topics (n = 35, 40%) and were in survey form (n = 75, 87%). Fidelity was the most frequently prevalent implementation outcome (n = 70, 81%), followed by adoption (n = 32, 81%). The implementation determinants most assessed were readiness for implementation, including resources (n = 43, 50%), leadership (n = 42, 49%), and policy communication (n = 41, 48%). Overall, measures were low-cost and had easy readability. However, lengthy tools and lack of reported validity/reliability data indicate low transferability.

CONCLUSIONS

Implementation science can contribute to more complete and rigorous assessment of school health policy implementation processes, which can improve implementation strategies and ultimately the intended health benefits. Several high-quality measures of implementation determinants and implementation outcomes can be applied to school health policy implementation assessment. Dissemination and implementation science researchers can also benefit from measurement experiences of school health researchers.

Barriers and facilitators influencing the sustainment of health behaviour interventions in schools and childcare services: a systematic review

Background

Sustainment has been defined as the sustained use or delivery of an intervention in practice following cessation of external implementation support. This review aimed to identify and synthesise factors (barriers and facilitators) that influence the sustainment of interventions (policies, practices, or programmes) in schools and childcare services that address the leading risk factors of chronic disease.

Methods

Seven electronic databases and relevant reference lists were searched for articles, of any design, published in English, from inception to March 2020. Articles were included if they qualitatively and/or quantitatively reported on school or childcare stakeholders’ (including teachers, principals, administrators, or managers) perceived barriers or facilitators to the sustainment of interventions addressing poor diet/nutrition, physical inactivity, obesity, tobacco smoking, or harmful alcohol use. Two independent reviewers screened texts, and extracted and coded data guided by the Integrated Sustainability Framework, an existing multi-level sustainability-specific framework that assesses factors of sustainment.

Results

Of the 13,158 articles identified, 31 articles met the inclusion criteria (8 quantitative, 12 qualitative, 10 mixed-methods, and 1 summary article). Overall, 29 articles were undertaken in schools (elementary n=17, middle n=3, secondary n=4, or a combination n=5) and two in childcare settings. The main health behaviours targeted included physical activity (n=9), diet (n=3), both diet and physical activity (n=15), and smoking (n=4), either independently (n=1) or combined with other health behaviours (n=3). Findings suggest that the majority of the 59 barriers and 74 facilitators identified to impact on intervention sustainment were similar across school and childcare settings. Factors predominantly relating to the ‘inner contextual factors’ of the organisation including: availability of facilities or equipment, continued executive or leadership support present, and team cohesion, support, or teamwork were perceived by stakeholders as influential to intervention sustainment.

Conclusions

Identifying strategies to improve the sustainment of health behaviour interventions in these settings requires a comprehensive understanding of factors that may impede or promote their ongoing delivery. This review identified multi-level factors that can be addressed by strategies to improve the sustainment of such interventions, and suggests how future research might address gaps in the evidence base.

Trial registration

This review was prospectively registered on PROSPERO: CRD42020127869, Jan. 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01134-y.

Evaluation of the Implementation of a 25-Year Outdoor School Ground Smoking Ban: A Qualitative Interview Study With Implications for Prevention Practise

Introduction: Tobacco use, often initiated in younger ages, is a serious health challenge worldwide. In Sweden, smoking has been prohibited on school grounds since 1994. Municipal environmental and health inspectors control the compliance of the ban. Nevertheless, the enforcement and maintenance of the ban are inadequate. The aim of the current study was to identify facilitators, barriers, and the potential for improved implementation of a 25-year outdoor school ground smoking ban in upper secondary schools.

Materials and Methods: A process evaluation was conducted using semi-structured interviews with principals in upper secondary schools, local environmental and health inspectors, and local politicians (n = 30) in Stockholm County, with purposive sampling for informant recruitment. A qualitative content analysis of the transcribed interviews was performed.

Results: Three main categories and 10 subcategories were generated from the interviews, revealing facilitators, barriers, and the potential for improvement of the implementation of the ban. A prominent facilitator of the ban was informed and engaged principals and inspectors. Prominent barriers were conflicting goals governing the schools, which reduce staffs' motivation to maintain the ban, unclear school ground boundaries, and lack of resources. Potential for improvement was found in a new tobacco act with an extended ban on smoking at school entrances, extended support for schools and staff to strictly enforce the ban, and a continued denormalisation of smoking in society.

Conclusion: To achieve effective implementation of outdoor school ground smoking bans in upper secondary schools, authorities need to address conflicts between different goals governing the schools and give necessary support to the staff to strictly enforce the ban. Policies on smoke-free working hours in the municipalities along with tobacco restrictive policies in the surrounding society may increase the possibility to maintain the smoking ban in upper secondary school grounds.

Quantitative measures of health policy implementation determinants and outcomes: a systematic review

BACKGROUND

Public policy has tremendous impacts on population health. While policy development has been extensively studied, policy implementation research is newer and relies largely on qualitative methods. Quantitative measures are needed to disentangle differential impacts of policy implementation determinants (i.e., barriers and facilitators) and outcomes to ensure intended benefits are realized. Implementation outcomes include acceptability, adoption, appropriateness, compliance/fidelity, feasibility, penetration, sustainability, and costs. This systematic review identified quantitative measures that are used to assess health policy implementation determinants and outcomes and evaluated the quality of these measures.

METHODS

Three frameworks guided the review: Implementation Outcomes Framework (Proctor et al.), Consolidated Framework for Implementation Research (Damschroder et al.), and Policy Implementation Determinants Framework (Bullock et al.). Six databases were searched: Medline, CINAHL Plus, PsycInfo, PAIS, ERIC, and Worldwide Political. Searches were limited to English language, peer-reviewed journal articles published January 1995 to April 2019. Search terms addressed four levels: health, public policy, implementation, and measurement. Empirical studies of public policies addressing physical or behavioral health with quantitative self-report or archival measures of policy implementation with at least two items assessing implementation outcomes or determinants were included. Consensus scoring of the Psychometric and Pragmatic Evidence Rating Scale assessed the quality of measures.

RESULTS

Database searches yielded 8417 non-duplicate studies, with 870 (10.3%) undergoing full-text screening, yielding 66 studies. From the included studies, 70 unique measures were identified to quantitatively assess implementation outcomes and/or determinants. Acceptability, feasibility, appropriateness, and compliance were the most commonly measured implementation outcomes. Common determinants in the identified measures were organizational culture, implementation climate, and readiness for implementation, each aspects of the internal setting. Pragmatic quality ranged from adequate to good, with most measures freely available, brief, and at high school reading level. Few psychometric properties were reported.

CONCLUSIONS

Well-tested quantitative measures of implementation internal settings were under-utilized in policy studies. Further development and testing of external context measures are warranted. This review is intended to stimulate measure development and high-quality assessment of health policy implementation outcomes and determinants to help practitioners and researchers spread evidence-informed policies to improve population health.

REGISTRATION

Not registered.

The Association Between School Tobacco Control Policies and Youth Smoking Behavior

BACKGROUND

While U.S. tobacco control policy has focused mainly on tobacco excise taxes, product advertising bans, and state tobacco control policies such as indoor/outdoor smoking bans, little attention has been paid to school tobacco control policies and their impact on youth smoking behavior. Thus, the objective of this study is to examine the impact of school tobacco control policies on smoking behavior among teenagers and young adults in the USA.

METHODS

Using logistic regression approach, this study examines the effect of school tobacco control policies on individuals ever trying smoking and ever being a regular smoker using data from waves I, II, and III of the National Longitudinal Study of Adolescent Health.

RESULTS

Findings indicate that school tobacco control policies targeting both students and employees of the school are associated with a reduced odds of smoking initiation among youth, but do not have much effect on youth becoming regular smokers.

CONCLUSIONS

If implemented properly, school tobacco control policies could play a vital role in preventing youth smoking and help reduce youth smoking rates in the country, addressing a key public health issue.

The sustainability of public health interventions in schools: a systematic review

BACKGROUND

The sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. If effective interventions discontinue, new practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? What are the barriers and facilitators affecting the sustainability of public health interventions in schools in high-income countries?

METHODS

Seven bibliographic databases and 15 websites were searched. References and citations of included studies were searched, and experts and authors were contacted to identify relevant studies. We included reports published from 1996 onwards. References were screened on title/abstract, and those included were screened on full report. We conducted data extraction and appraisal using an existing tool. Extracted data were qualitatively synthesised for common themes, using May's General Theory of Implementation (2013) as a conceptual framework.

RESULTS

Of the 9677 unique references identified through database searching and other search strategies, 24 studies of 18 interventions were included in the review. No interventions were sustained in their entirety; all had some components that were sustained by some schools or staff, bar one that was completely discontinued. No discernible relationship was found between evidence of effectiveness and sustainability. Key facilitators included commitment/support from senior leaders, staff observing a positive impact on students' engagement and wellbeing, and staff confidence in delivering health promotion and belief in its value. Important contextual barriers emerged: the norm of prioritising educational outcomes under time and resource constraints, insufficient funding/resources, staff turnover and a lack of ongoing training. Adaptation of the intervention to existing routines and changing contexts appeared to be part of the sustainability process.

CONCLUSIONS

Existing evidence suggests that sustainability depends upon schools developing and retaining senior leaders and staff that are knowledgeable, skilled and motivated to continue delivering health promotion through ever-changing circumstances. Evidence of effectiveness did not appear to be an influential factor. However, methodologically stronger primary research, informed by theory, is needed.

TRIAL REGISTRATION

The review was registered on PROSPERO: CRD42017076320, Sep. 2017.

Results of outdoor smoking bans at secondary schools on adolescents smoking behaviour: a quasi-experimental study

BACKGROUND

Research on the effectiveness of school smoking policies on adolescents' smoking behaviour remain inconclusive. This study evaluates the results of an outdoor school ground smoking ban at secondary schools on adolescents smoking behaviour, taking individual characteristics into account.

METHODS

Data on 2684 adolescents from 18 Dutch secondary schools (nine with and nine without an outdoor smoking ban) were obtained at two moments. Associations between outdoor school ground smoking bans, individual characteristics, and smoking prevalence and frequency were measured. Multilevel logistic regression analyses were used. At schools with a ban implementation fidelity was checked.

RESULTS

Although smoking prevalence and frequency appeared to make a slower increase at schools with an outdoor smoking ban compared with schools without an outdoor smoking ban, the differences were not significant. Differences between schools in the prevalence of smoking behaviour of students could mainly be explained by individual characteristics. Smoking prevalence and frequency were higher among adolescents with a positive attitude towards smoking and when significant others were more positive about smoking. Smoking prevalence and frequency were significantly lower when adolescents perceived it as easy not to smoke. Implementation fidelity was good at schools with a ban.

CONCLUSIONS

No short-term effects were found of an outdoor smoking ban. A longer follow-up time than 6 months is needed. In addition, future research should investigate effectiveness in relation to the enforcement of the ban, comprehensiveness of the ban and when it is prohibited to leave school grounds, as smoking behavior might be transferred off school grounds.

Understanding school staff members' enforcement of school tobacco policies to achieve tobacco-free school: a realist review

BACKGROUND

School tobacco policies (STPs) that aim to achieve a tobacco-free environment require consistent enforcement by school staff. However, little is known about why staff choose whether or not to enforce STPs. Therefore, we investigated staff members' responses to STPs that determine enforcement. Furthermore, we examined how these responses depend on contextual factors at the individual, interpersonal, school, implementation, and national levels.

METHODS

We performed a realist review (RR), which synthesizes existing primary evidence into a programme theory demonstrating key causal pathways through Context-Mechanism-Outcome configurations (CMOs). These CMOs link contextual factors to outcomes (i.e. staff enforcement) by explaining the underlying generative mechanisms (i.e. staff members' cognitive, psychosocial, and behavioural responses). A systematic literature search for the period 2000-2016 was performed using Academic Search Premier, PsycInfo, and MEDLINE. Forty English-language articles were identified for the synthesis.

RESULTS

Our programme theory demonstrated three CMOs: when contextual factors make staff members experience STP enforcement as part of their professional role and duties, it may lead to staff members showing responsibility for STP enforcement (CMO1); when contextual factors make staff members feel their contribution is leading to positive outcomes, it may lead to staff members showing motivation to enforce STPs (CMO2), and when contextual factors make staff members feel that they are able to deal with students' responses, it may lead to staff members showing confidence in STP enforcement (CMO3). Moreover, the programme theory provided more precise insights into what contextual factors contribute to triggering the individual mechanisms and the consequent outcomes.

CONCLUSIONS

By applying a realist approach, we have been able to detect three CMOs explaining staff members' STP enforcement. The findings provide useful insights explaining how stakeholders can support staff members' STP enforcement and consequently improve the impact of STPs on adolescent smoking.

Evaluation of the Process of Implementing an Outdoor School Ground Smoking Ban at Secondary Schools

BACKGROUND

Although outdoor smoking bans at school are becoming important, it remains unclear whether successful implementation is feasible and what conditions promote it. Therefore, this study evaluates the implementation process by identifying important factors.

METHODS

Interviews were held with directors of 24 secondary schools that had decided to implement an outdoor school ground smoking ban, to identify important factors during implementation. Additionally, observations were made before and (about 4 weeks) after implementation to evaluate adherence to guidelines. Data were analyzed using a thematic approach.

RESULTS

During implementation, the following items were important: smoking ban (eg, guidelines), school (eg, policy, enforcement, environmental factors, resources, etc), and external factors (eg, social environment). Four schools were unable to implement the ban, 20 schools implemented the ban but student adherence was low, and at 4 schools, staff members still smoked on school grounds.

CONCLUSIONS

Although implementation is feasible, there are challenges. Schools need to apply a phased/dynamic process with ample lead time and clear communication of the policy. Directors should deal with offenders by strictly enforcing the ban and helping them stop smoking. This study offers information to help institutes implement an outdoor smoking ban to further protect adolescents from the harm of smoking.

E-cigarette and waterpipe use in two adolescent cohorts: cross-sectional and longitudinal associations with conventional cigarette smoking

Alternative tobacco products are increasing in popularity. An important question is whether their use is associated with or even leads to conventional smoking, but large-scale (European) studies are scarce. In two cohorts of Dutch adolescents (Cohort I n = 6819, mean age = 13.8 SD = 1.1, 48.2% female; Cohort II n = 2758, mean age = 17.3 SD = 1.8, 61.3% female), we investigated use of electronic (e)-cigarettes with nicotine, e-cigarettes without nicotine and waterpipe. Generalized estimating equation modelling was conducted with ever conventional smoking as the dependent variable (0 = no, 1 = yes) and ever alternative tobacco use as the independent variable, correcting for clustering within schools, age, sex and education in both cohorts. In a subsample (n = 2100), the association between alternative tobacco use at baseline and conventional smoking 6 months later was tested, taking into account smoking propensity (based on personality, susceptibility to peer pressure and smoking intentions). Ever use prevalence was 13.7% for e-cigarettes with nicotine, 29.4% for e-cigarettes without nicotine and 22.1% for waterpipe in Cohort I and 12.3, 27.6 and 45.3% respectively in Cohort II. Ever smokers had tried alternative tobacco products more often than never smokers. Among never-smoking adolescents at baseline, alternative tobacco use predicted ever smoking 6 months later (e-cigarettes with nicotine OR 11.90 95% CI 3.36-42.11; e-cigarettes without nicotine OR 5.36 95% CI 2.73-10.52; waterpipe OR 5.36 95% CI 2.78-10.31). This association was strongest for adolescents with a low baseline risk of smoking. Experimenting with alternative tobacco products is common among Dutch youth. Alternative tobacco use predicts (future) smoking, especially among adolescents with a low smoking propensity.

Impact of an Outdoor Smoking Ban at Secondary Schools on Cigarettes, E-Cigarettes and Water Pipe Use among Adolescents: An 18-Month Follow-Up

The effectiveness of outdoor smoking bans on smoking behavior among adolescents remains inconclusive. This study evaluates the long-term impact of outdoor school ground smoking bans among adolescents at secondary schools on the use of conventional cigarettes, e-cigarettes (with/without nicotine) and water pipes. Outdoor smoking bans at 19 Dutch secondary schools were evaluated using a quasi-experimental design. Data on 7733 adolescents were obtained at baseline, and at 6 and 18-month follow-up. The impact of outdoor smoking bans on ‘ever use of conventional cigarettes’, ‘smoking onset’, ‘ever use of e-cigarette with nicotine’, ‘e-cigarette without nicotine’, and ‘water pipe’ was measured. Multilevel logistic regression analysis was used. At schools with a ban, implementation fidelity was checked. At schools where a ban was implemented, at 18-month follow-up more adolescents had started smoking compared to the control condition. No effect of implementation of the ban was found for smoking prevalence, e-cigarettes with/without nicotine, and water pipe use. Implementation fidelity was sufficient. No long-term effects were found of an outdoor smoking ban, except for smoking onset. The ban might cause a reversal effect when schools encounter difficulties with its enforcement or when adolescents still see others smoking. Additional research is required with a longer follow-up than 18 months.