School-based drama interventions in health promotion for children and adolescents: systematic review

As Much As I Can - Utilizing Immersive Theatre to Reduce HIV-Related Stigma and Discrimination Toward Black Sexual Minority Men

BACKGROUND

Despite advances in biomedical HIV prevention modalities such as pre-exposure prophylaxis to prevent the transmission of HIV, racial/ethnic and sexual/gender minority populations are disproportionately impacted by HIV epidemic. Alarming rates of HIV have persisted among Black gay and bisexual men, particularly in Southern states.

METHODS

Utilizing data from the ViiV ACCELERATE! initiative, we explored the impact of As Much As I Can, an immersive theatre production, on HIV-related stigma behaviors. A self-administered post-performance survey was conducted with a cohort (n = 322) of randomly selected audience members.

RESULTS

Overall, the results showed participants had a highly favorable experience, rating the performance with a mean score of 9.77/10. Respondents indicated they intended to change behaviors to promote HIV prevention education and to reduce stigma and discrimination including: (1) Say something if I hear stigmatizing language against people living with HIV (75.4%), (2) Say something if I hear anti-gay language (69.7%) and (3) Tell others about HIV prevention options (e.g., PrEP, PEP, condoms (64.1%). The findings show there is an association between HIV-related behavior intention and linkage to HIV care. Respondents who reported they were more likely to say something about HIV stigma were almost three times (O.R. 2.77; 95% C.I. 0.98-7.8) more likely to indicate they would follow up with a healthcare professional.

CONCLUSIONS

This study suggests that immersive theatre is an effective method for communicating HIV prevention education and reducing HIV-related structural stigma and discrimination that increases HIV vulnerability for Black sexual minority men.

Multi-level meta-analysis of whether fostering creativity during physical activity interventions increases their impact on cognitive and academic outcomes during childhood

Neuroplasticity research supports the idea that varied practice and new environments promote cognitive engagement and enhance learning. Expanding on a meta-analysis of the effect of physical activity interventions on cognition and academic outcomes, we reviewed and quantified the impact of task and environmental factors that foster creative physical activity. Interventions were considered as fostering creative physical activity to a greater extent if (1) they were varied, (2) relied less on technical acquisition, instruction or demonstration, (3) involved open spaces, props, or open-ended instructions, and (4) involved interactions with peers. A wide range of physical activities were considered, from dance to aerobic exercise across 92 studies in 5-12-year-old children. Creativity ratings of physical activity interventions were varied but did not associate with greater beneficial effects on executive functions (k = 45), academic achievement (k = 47), or fluid intelligence (k = 8). Studies assessing on-task behaviour (k = 5) tended not to foster creativity, while reversely studies assessing creativity tended to foster creative physical activities (k = 5). As a group, three studies that fostered more creative PA showed a small significant negative summary effect on cognitive flexibility. Considering qualitative differences in the physical activities performed in schools will improve our understanding of their mechanisms of impact. Future research should consider using more varied measures, including more proximal outcomes that involve body movements (e.g., a Simon Says task to measure inhibitory control).

Mental Health and Positive Development Prevention Interventions: Overview of Systematic Reviews

CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10-19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5-10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5-14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5-14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

Cluster Randomized Trial: Sun Protection Intervention 'Clever in Sun and Shade for Preschools'-Effectiveness and Dissemination

Skin cancer is one of the most common types of cancer and UV radiation is one of the main risk factors. Therefore, sun protection, especially in childhood, is strongly recommended. We examined the effectiveness of the ‘Clever in Sun and Shade for Preschools’ program (CLEVER) in promoting sun protection behavior among preschool staff (trial registration: DRKS00023468) and describe its dissemination. Within a cluster randomized trial with 24 preschools (n = 273 staff members) stating a high need for sun protection measures, an educational workshop for preschool staff and a project kit with materials applicable in preschool groups was provided. Staff members of preschools taking part in CLEVER report significantly stronger sun protection behavior to avoid the sun (effect size [ES] 0.70, 95% confidence interval [CI] 0.04 0.71, p < 0.05) and less perceived impediments to avoid the sun (ES −0.56, CI −0.82 −0.17, p < 0.01) after 12 months as well as higher self-efficacy to avoid the sun (ES 1.09, CI 0.39 1.07, p < 0.001) and to use sunscreen (ES 0.71, CI 0.03 0.88, p < 0.05) after 1 month. Compared to the control group, there was no significant effect on sunscreen use and further psychosocial outcomes. The effectiveness of CLEVER may be underrated due to a high drop-out rate. Within three years, an enhanced free-of-charge program kit, including a media-based workshop and materials, had reached over 4000 preschools, i.e., 7.1% of all daycare centers in Germany. The results show that CLEVER can strengthen sun protection, offer high-quality information at low cost, and is easily disseminable.

Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis

BACKGROUND

Educational interventions engage youth using visual, literary and performing arts to combat stigma associated with mental health problems. However, it remains unknown whether arts interventions are effective in reducing mental-health-related stigma among youth and if so, then which specific art forms, duration and stigma-related components in content are successful.

METHODS

We searched 13 databases, including PubMed, Medline, Global Health, EMBASE, ADOLEC, Social Policy and Practice, Database of Promoting Health Effectiveness Reviews (DoPHER), Trials Register of Promoting Health Interventions (TRoPHI), EPPI-Centre database of health promotion research (Bibliomap), Web of Science, PsycINFO, Cochrane and Scopus for studies involving arts interventions aimed at reducing any or all components of mental-health-related stigma among youth (10-24-year-olds). Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Data were extracted into tables and analysed using RevMan 5.3.5.

RESULTS

Fifty-seven studies met our inclusion criteria (n = 41,621). Interventions using multiple art forms are effective in improving behaviour towards people with mental health problems to a small effect (effect size = 0.28, 95%CI 0.08-0.48; p = 0.007) No studies reported negative outcomes or unintended harms. Among studies using specific art forms, we observed high heterogeneity among intervention studies using theatre, multiple art forms, film and role play. Data in this review are inconclusive about the use of single versus multiple sessions and whether including all stigma components of knowledge, attitude and behaviour as intervention content are more effective relative to studies focused on these stigma components, individually. Common challenges faced by school-based arts interventions included lack of buy-in from school administrators and low engagement. No studies were reported from low- and middle-income countries.

CONCLUSION

Arts interventions are effective in reducing mental-health-related stigma to a small effect. Interventions that employ multiple art forms together compared to studies employing film, theatre or role play are likely more effective in reducing mental-health-related stigma.

Age-Related Differential Effects of School-Based Sitting and Movement Meditation on Creativity and Spatial Cognition: A Pilot Study

Psychophysical well-being can be supported during development by the integration of extra-curricular activities in scholastic settings. These activities can be implemented in different forms, ranging from physical activities to sitting meditation practices. Considering that both such activities are thought to affect children’s psychophysical development, a movement-based meditation that combines the two approaches−in the form of a short daily activity−could represent a powerful tool to promote healthy physical and mental development. Consequently, the current pilot study aimed to examine the effect of short daily school-based sitting and movement meditation trainings on creativity and spatial cognition. Utilizing a crossover design, we evaluated their feasibility and efficacy at different ages among children (n = 50) in 5th to 8th grade. We observed that 5 weeks of daily training in sitting and movement meditation techniques improved children’s cognition differently. Specifically, younger children showed greater creativity and better spatial cognition following the movement-based meditation, while older children showed greater enhancement in these areas following sitting meditation training. This suggests that training can affect children’s cognition differently depending on their developmental stage. We discuss these results within the framework of embodied and grounded cognition theories. Information on feasibility and age-related effect sizes derived from the current study paves the way for future well-powered larger-scale efficacy studies on different forms of school-based interventions to cognitive development promotion.

Engaging ethnic minority communities through performance and arts: health education in Cambodian forest villages

Background

In Siem Pang, northeastern Cambodia, malaria transmission persists in remote forested areas populated by ethnic minorities. Engaging affected communities in health education campaigns is challenging due to language, access and literacy constraints. During 2018, a newly established medical research station conducted a health education programme in local villages harnessing traditional songs, arts and crafts, along with theatre, comedy and health talks and quizzes. Health education topics were proposed by community leaders and focused on maternal and child health and malaria. This article describes a process evaluation of these activities, the community's response and whether this was an appropriate form of health education in this context.

Methods

In-depth interviews were conducted with community members, leaders and performers. Interviews were audio-recorded, transcribed and translated to English for thematic analysis.

Results

In total, 65 interviews were conducted; 20 of these were follow-up interviews with respondents interviewed prior to the performances. Respondents were able to recall the key health messages about malaria, antenatal care and infant vaccination. They also showed good awareness of malaria transmission and prevention and described how they enjoyed the events and appreciated the efforts of the project team.

Conclusions

In isolated communities in Cambodia, a health education programme harnessing performance and arts engaged the whole community and its messages were readily recalled and prompted reflection.

Efficacy of a Community Health Worker-Based Intervention in Improving Dietary Habits Among Community-Dwelling Older People: A Controlled, Crossover Trial in Japan

Background. Community health workers (CHWs), often called "health promotion volunteers" in Japan, are individuals who act as a natural helping resource in the community. Aim. This study tested the efficacy of a CHW-based intervention to improve dietary habits among community-dwelling older people in Japan, using a controlled, crossover design. Method. Seventy-eight people aged 65 to 74 years with poor dietary variety living in four administrative districts in Hikone City (Shiga Prefecture, Japan) were nonrandomly allocated to an immediate-intervened group (IIG; n = 41) or a delayed-intervened group (DIG; n = 37). Participants joined a biweekly, four-session program (120 minutes/session), comprising "CHW drama-style lectures," "group discussion among participants and CHWs," "tasting of dishes," and "take-home practical activities." For the initial 2-month period, the IIG received the intervention and the DIG did not. The groups were crossed over for the subsequent 2-month period. The primary outcome measure was participants' dietary variety score (score range: 0-10). Results. The dietary variety score in the IIG significantly increased in the initial 2-month period compared with the DIG (effect size 1.60 points; 95% confidence interval: 0.75, 2.45). The intervention had a similar effect in the DIG in the subsequent 2-month period. Moreover, an analysis within the IIG showed that the intervention effects persisted for at least 2 months after the intervention. Conclusions. The CHW-based intervention improved dietary habits among older people. Our findings provide evidence that a CHW-based natural helping approach is a possible solution to promote healthy aging in the community.

Using process drama to explore the causes of dental anxiety in primary-school children

Background

Drama and role play can be unlisted as methods to allow children to view problems from a range of different perspectives that may differ from their own experience. Application of drama technique to assess the cause of dental fear and anxiety in a school setting is novel.

Aim

The aim of this study was to engage primary school children in the core investigation via participatory arts methodologies, namely, process drama to gain understanding of the causes of dental anxiety.

Design

Sixty-three children, aged 7–10 years from three primary schools participated in this study. A 90-min drama workshop was carried in each school. The children were encouraged to identify the causes of dental anxiety using key concepts from process drama. The sessions were audio-recorded and transcribed.

Results

Four key concepts emerged: (1) fear of the unknown; (2) unpleasant sensory experience; (3) society’s perception and portrayal of the dentist; and (4) learnt negative associations with the dentist. Within each four key concepts, two sub-themes were identified.

Conclusions

Role-playing and use of drama are a novel application and can reveal a considerable amount of information from the child’s perspective on the cause of dental fear and anxiety.

A Peer-Based Strategy to Overcome HPV Vaccination Inequities in Rural Communities: A Physical Distancing-Compliant Approach

The human papilloma virus (HPV) vaccine is the world's first proven and effective vaccine to prevent cancers in males and females when administered pre-exposure. Like most of the US, barely half of Vermont teens are up-to-date with the vaccination, with comparable deficits in New Hampshire and Maine. The rates for HPV vaccine initiation and completion are as low as 33% in rural New England. Consequently, there is a compelling responsibility to communicate its importance to unvaccinated teenagers before their risk for infection increases. Messaging in rural areas promoting HPV vaccination is compromised by community-based characteristics that include access to appropriate medical care, poor media coverage, parental and peer influence, and skepticism of science and medicine. Current strategies are predominantly passive access to literature and Internet-based information. Evidence indicates that performance-based messaging can clarify the importance of HPV vaccination to teenagers and their parents in rural areas. Increased HPV vaccination will significantly contribute to the prevention of a broadening spectrum of cancers. Reducing rurality-based inequities is a public health priority. Development of a performance-based peer-communication intervention can capture a window of opportunity to provide increasingly effective and sustained HPV protection. An effective approach can be partnering rural schools and regional health teams with a program that is nimble and scalable to respond to public health policies and practices compliant with COVID-19 pandemic-related modifications on physical distancing and interacting in the foreseeable future.

Narrative Engagement and Interpersonal Communication about Substance Use on Adolescent Substance Use Behaviors: A Case Study of keepin' it REAL

The present study examined direct and indirect effects of adolescent narrative engagement on substance use behaviors via refusal self-efficacy. This study also tested moderation effects of communication about substance use with parents, siblings, and friends on substance use behaviors. Students in 8^th grade (N = 225) participated in surveys at two different time points. Path analyses revealed a positive association between identification with main characters and refusal self-efficacy as well as negative associations between refusal self-efficacy and the past 30-days substance use. Communication with parents and friends significantly moderated the relationship between refusal self-efficacy and the past 30-days substance use.

'The Mould that Changed the World': Quantitative and qualitative evaluation of children's knowledge and motivation for behavioural change following participation in an antimicrobial resistance musical

BACKGROUND

A primary school musical ("The Mould that Changed the World") was developed as a unique public engagement strategy to combat antimicrobial resistance (AMR) by engaging children in the story of the discovery of antibiotics, the risks of drug-resistant infections and the importance of prudent antibiotic use.

METHODS

The musical intervention was implemented in two UK primary schools by music specialists through a series of workshops, associated learning resources and performances to relatives. Participating children (n = 182), aged 9 to 11 years, were given an online questionnaire in the classroom before rehearsals began and at two weeks post-performance with a six-month evaluation in one school. The impact of the musical was analysed using generalised linear models to control for confounding factors. For the qualitative evaluation, fifteen participating children were selected randomly from each school to take part in semi-structured focus groups (n = 5 per group) before rehearsals began and two weeks post-performance.

FINDINGS

Knowledge gain was demonstrated with children being more likely to answer questions on key messages of the musical correctly at two weeks post- performance (response rate 88%, n = 161) compared with the pre-rehearsal questionnaire (response rate 99%, n = 180) (bacteria can become resistant to antibiotics OR 4.63, C.I. 2.46-9.31 p<0.0001, antibiotic resistant infections can be life threatening OR 3.26 C.I. 1.75-6.32 p = 0.0001, prudent use of antibiotics will slow the rise of antibiotic resistant infections OR 2.16, C.I. 1.39-3.38, p = 0.0006). Long term knowledge gain was demonstrated by a consistent level of correct answers on key messages between two weeks (response rate 95%, n = 89) and 6 months post musical (response rate 71%, n = 67). Following the musical children participating in the focus groups (n = 30) articulated a greater understanding of AMR and the risks of antibiotic overuse. They discussed motivation to minimise personal antibiotic use and influence attitudes to antibiotics in their family and friends.

INTERPRETATION

This study demonstrates that musical theatre can improve both short and long-term knowledge. It demonstrates a hitherto infrequently reported change in attitude and motivation to change behaviour in children at an influential age for health beliefs. This unique public health tool has the potential for high impact particularly if rolled out within national education programmes for primary school aged children.

Developing a theory-based multimedia intervention for schools to improve young people's asthma: my asthma in school (MAIS)

Background

Asthma control in adolescents is low with half of the young people in a London study identified as having suboptimal control when measured using the Asthma Control Test. Control of asthma symptoms can be improved by addressing barriers to good self-management, such as poor understanding of asthma and adherence to medication. The aim of this study was therefore to develop the My Asthma in School (MAIS) intervention for the improvement of asthma control and self-management in adolescents and to test its initial feasibility. The intervention intended to combine a strong focus on theory with a design specifically aimed to engage adolescents.

Methods

The intervention development was based on previous qualitative and quantitative findings, and on guidelines from the Medical Research Council for the development of complex interventions. The COM-B (Capability, Opportunity, Motivation-Behaviour) model was applied to inform the design of intervention elements. Behavioural targets were identified from existing barriers to good asthma self-management and were then used to guide the development of engaging intervention elements, which were described using the Behavioural Change Technique (BCT) Taxonomy version 1. Adolescents were involved throughout this process. The MAIS intervention was tested in a feasibility phase in London secondary schools with adolescents aged between 11 and 13.

Results

The complex school-based MAIS intervention comprised a first school visit from a theatre group, who conducted a workshop with all year 7-8 students and addressed peer understanding and attitudes to asthma. The second visit included four self-management workshops for adolescents with asthma, including games, short-films and role play activities. Forty different types of techniques to change behaviour were applied, totalling 163 instances of BCT use across intervention elements, addressing all areas of capability, opportunity and motivation. In this initial feasibility study, 1814 adolescents with and without asthma from nine schools received the theatre intervention visit; 23 adolescents with asthma from one of the schools attended the workshop visit. The intervention was found acceptable and engaging, and 91.4% of participants agreed that the workshops changed how they think or feel about asthma.

Conclusion

This study demonstrates development and initial feasibility of a complex theory-based intervention, and how it can combine engaging media and interactive elements, to achieve a multi-directional approach to behavioural change. However more work is needed to assess the feasibility of trial processes, including recruitment and delivery format of the workshops.

The Effect of Diet-Exercise Trainings Provided to Overweight and Obese Teenagers through Creative Drama on Their Knowledge, Attitude, and Behaviors

BACKGROUND

This study was conducted in Turkey as an empirical study in randomized, controlled, and time series design for the purpose of evaluating the effects of the Diet-Exercise trainings with creative drama method provided to overweight/obese teenagers.

METHODS

This study was designed to highlight the effect of interactive education provided to slightly overweight/obese teenagers through creative drama on modifiable factors that caused obesity. Seventy-six overweight/obese teenagers studying at sixth and seventh grades of upper primary education were included in the study (38 participants in the Study Group and 38 participants in the Control Group). Training courses that were designed based on creative drama method were implemented in five sessions with teenager groups (n = 12-13); and the mothers were also trained in a session in this study (for the Study Group).

RESULTS

At the end of the study, it was determined that the knowledge, attitude, the order of the meals, and healthy diet-exercise behavior points of the teenagers in the Study Group increased; and the difference between the Study Group and the Control Group was significant (p < 0.05). The BMI, body weight, and waist/height rate of the teenagers in the Study Group decreased at a significant level after the study was completed (p < 0.05); and significant increases were determined in the waist circumference and body weight measurements of the Control Group (p < 0.05).

CONCLUSIONS

As a conclusion, overweight/obese teenagers may be reached with school-based educational programs, and they may be made to acquire positive attitudes and behaviors through diet and exercises designed with interactive methods like creative drama.

Effects of the ACT OUT! Social Issue Theater Program on Social-Emotional Competence and Bullying in Youth and Adolescents: Protocol for a Cluster Randomized Controlled Trial

Background

Students in the United States spend a meaningful portion of their developmental lives in school. In recent years, researchers and educators have begun to focus explicitly on social and emotional learning (SEL) in the school setting. Initial evidence from meta-analyses suggests that curricula designed to promote SEL likely produce benefits in terms of social-emotional competence (SEC) and numerous related behavioral and affective outcomes. At the same time, there are often barriers to implementing such curricula as intended, and some researchers have questioned the strength of the evaluation data from SEL programs. As part of the effort to improve programming in SEL, this paper describes the protocol for a cluster randomized trial of the ACT OUT! Social Issue Theater program, a brief psychodramatic intervention to build SEC and reduce bullying behavior in students.

Objective

The objective of this trial is to examine if a short dose of interactive psychodrama can affect SEC metrics and bullying experiences in schoolchildren in either the short (2-week) or medium (6-month) term.

Methods

The ACT OUT! trial is a cluster randomized superiority trial with 2 parallel groups. The unit of measurement is the student, and the unit of randomization is the classroom. For each grade (fourth, seventh, and 10th), an even number of classrooms will be selected from each school—half will be assigned to the intervention arm and half will be assigned to the control arm. The intervention will consist of 3 moderated psychodramatic performances by trained actors, and the control condition will be the usual school day. Outcome data will be collected at baseline (preintervention), 2-week postintervention (short term), and 6-month postintervention (medium term). Outcomes will include social-emotional competency; self-reported bullying and experiences of being bullied; receptivity to the program; and school-level data on truancy, absenteeism, and referrals to school displinary action for bullying. A power analysis adjusted for clustering effect, design effect, and potential attrition yielded a need for approximately 1594 students, consisting of an estimated 80 classrooms split evenly into intervention and control arms.

Results

This study was funded in June 2019; approved by the Indiana University Institutional review board on September 17, 2019; began subject recruitment on November 5, 2019; and prospectively registered with ClinicalTrials.gov.

Conclusions

Many states have issued recommendations for the integration of SEL into schools. The proposed study uses a rigorous methodology to determine if the ACT OUT! psychodramatic intervention is a cost-effective means of bolstering SEC and reducing bullying incidence in schools.

Trial Registration

ClinicalTrials.gov NCT04097496; https://clinicaltrials.gov/ct2/show/NCT04097496

International Registered Report Identifier (IRRID)

PRR1-10.2196/17900

The Effect of Behavioral System Model Based Nursing Intervention on Adolescent Bullying

Aim

The study was conducted experimentally with pre-post tests and a control group to determine the effect of Behavioral System Model based education that given by the creative drama method on adolescent bullying.

Method

As a result of the power analysis performed, eighty-three students (43 in study group, 40 in control group) attending 7^th degree were recruited. Education is given in nine sessions with creative drama method. Data were collected with Individual Information Form, Traditional Peer Bullying Scale, Problem-Solving Inventory for Children, and the Empathy Index for Children. Data were analyzed with decrease/increase in percentage, Cronbach α, chi-square, two way/two factor repeated measures analysis of variance (Post-Hoc: Bonferroni) and Mann-Whitney U tests.

Results

The decrease in percentage in the mean Traditional Peer Bullying Scale scores of study group students was higher than those of control group (p<0.05). Mean pre-education 1st measurement Traditional Peer Bullying Scale scores of study group students were reduced in the post-education 2^nd and 3^rd measurements (p<0.05). The increase in percentage in the mean Problem-Solving Inventory for Children and Empathy Index for Children scores of study group students was higher than those of control group (p<0.05). The mean pre-education 1^st measurement scores of PSIC and Empathy Index for Children was increased in post-education 2^nd and 3^rd measurements (p<0.05).

Conclusion

Drama education is effective on prevention of bullying, and that may be used in prevention programs.

B!RTH: a mixed-methods survey of audience members' reflections of a global women's health arts and science programme in England, Ireland, Scotland and Switzerland

OBJECTIVE

Public engagement and science communication are growing as an important forum in the design and dissemination of research. The B!RTH programme is a partnership that uses theatre in combination with scientific expert panel discussions to raise awareness about the global inequality in women's health and access to healthcare. As part of this project, we assessed the views and experiences of audiences participating in B!RTH events.

DESIGN

We conducted a multi-site mixed-methods survey using paper-based questionnaires.

SETTINGS

Data were collected at four B!RTH theatre and science events: Dublin (Ireland), Edinburgh (Scotland), Geneva (Switzerland) and Liverpool (England) after the performance of four plays and three expert panel discussions.

PARTICIPANTS

All audience members.

METHODS

Descriptive analysis was conducted for the responses to the closed-ended survey questions, and thematic analysis was used for written free text provided.

RESULTS

The estimated response rate was 42%; 363 members of the audiences responded. Most respondents had been emotionally moved by the performances (92.8%) and felt challenged and provoked (80.7%). Many respondents (73.6%) agreed that their eyes had been opened by new ideas. Five themes emerged from the free-text analysis: (1) an expression of thanks and positive feedback on the content and performance of the plays, (2) the benefit of and innovative use of art and science, (3) personal feelings in response to the plays and panel discussions, (4) the need for action and (5) suggestions for use of the plays and panel discussions in schools and universities to 'bring to life the human story behind the statistics'.

CONCLUSIONS

The B!RTH programme highlights how art and science can be used in partnership and is an effective tool to engage the public, to deliver key messages and to raise awareness about inequalities in global maternal and reproductive healthcare issues.

A community-based education programme to reduce insecticide exposure from indoor residual spraying in Limpopo, South Africa

Background

Indoor residual spraying (IRS), the coating of interior walls of houses with insecticides, is common in malaria-endemic areas. While important in malaria control, IRS potentially exposes residents to harmful insecticides. The World Health Organization recommends steps to minimize exposure; however, no programme has focused on educating populations.

Methods

A dramatic presentation and song were developed by study personnel and performed by lay performers in order to spread awareness of the importance of IRS and to minimize insecticide exposure. Performances were staged at 16 sprayed villages in the Vhembe District of Limpopo, South Africa, at which 592 attendees completed short questionnaires before and after the performance about behaviors that might limit insecticide exposure. Overall indices of the attendees’ change in knowledge of precautions to take prior to and after spraying to prevent insecticide exposure were analyzed using hierarchical mixed models to assess the effect of the performance on change in participants’ knowledge.

Results

Approximately half of attendees lived in homes that had been sprayed for malaria and 62% were female. Over 90% thought it better to allow IRS prior to the presentation, but knowledge of proper precautions to prevent exposure was low. The proportion answering correctly about proper distance from home during spraying increased from 49.4% pre-performance to 62.0% post-performance (RR = 1.26, 95% CI = 1.13, 1.41), and the proportion reporting correctly about home re-entry interval after spraying increased from 58.5 to 91.1% (RR = 1.54, 95% CI 1.35, 1.77). Attendees improved in their knowledge about precautions to take prior to and after spraying from mean of 57.9% correct to a mean of 69.7% (β = 12.1%, 95% CI 10.9, 13.4). Specifically, increased knowledge in closing cupboards, removing food and bedding from the home, covering immoveable items with plastic, and leading animals away from the home prior to spraying were observed, as was increased knowledge in sweeping the floors, proper disposal of dead insects, and discarding dirty washrags after spraying.

Conclusions

A dramatic presentation and song were able to increase the attendees’ knowledge of precautions to take prior to and after spraying in order to limit their insecticide exposure resulting from IRS. This approach to community education is promising and deserves additional study.

Pilot testing Fostering Open eXpression among Youth (FOXY), an arts-based HIV/STI prevention approach for adolescent women in the Northwest Territories, Canada

Fostering Open eXpression among Youth (FOXY) is an arts-based HIV prevention program developed by Northern Canadians to address sexual health, HIV, sexually transmitted infections (STIs), sexuality, and healthy relationships among Northern and Indigenous youth in Canada. We conducted a pilot study with Indigenous and Northern young women aged 13-17 years from 17 communities in the Northwest Territories to evaluate whether, in comparison to pre-intervention, FOXY participants demonstrated increased knowledge of STIs, increased safer sex self-efficacy, and increased resilience. Wilcoxon test results indicated significant increases in STI knowledge scores and safer sex self-efficacy scores. Findings suggest that FOXY holds promise as an effective method of delivering sexual health information through peer education, and increasing STI knowledge, safe sex self-efficacy, and resilience.

An Integrated Theatre Production for School Nutrition Promotion Program

In the context of stubbornly high childhood obesity rates, health promotion activities in schools provide a potential avenue to improve children’s nutritional behaviours. Theatre production has a rich history as a health behaviour promotion strategy but lacks sound, outcome-based evaluation. This study evaluated the effect of an integrated, two-part, place-based theatre performance program with 212 students in five schools in a regional urban and semi-rural area. The program included a theatre performance and a healthy eating competition. A brief survey assessed student healthy eating knowledge and attitudes at three time points. Nutrition behaviour was measured by scoring the contents of children’s lunch boxes before, during and up to six weeks after the intervention. Statistical analysis tested change over time on five variables (Knowledge, Attitude, Sometimes foods, Everyday foods, Overall lunch box score). Results showed that both components of the integrated program improved nutrition knowledge and that the theatre performance improved children’s healthy eating attitudes. All three lunch box scores peaked after the integrated program and remained significantly higher than baseline at 4–6 weeks follow-up. Interaction effects were identified for school catchment area on four of the five dependent variables. Evaluation of this integrated theatre production program indicates the potential benefit of taking a “super-setting” approach. It demonstrates an effect from students taking home information they had learned and incorporating it into lunch box preparation. It also showed consistent effects for school geographical catchment. This study suggests that, with careful, theory-based design, theatre productions in schools can improve student nutritional activities.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Sexual Health Transformation Among College Student Educators in an Arts-Based HIV Prevention Intervention: A Qualitative Cross-Site Analysis

We examined the sexual health change process experienced by 26 college student sexual health educators from three geographic regions of the United States who participated in a multisite arts-based sexual health prevention program. We conducted eight focus groups and used a phenomenological approach to analyze data. We drew from social cognitive theory (SCT) to examine how sexual health knowledge, attitudes, self-efficacy, and communication shifted across the duration of participation. Findings suggest that the college student sexual health educators (a) developed enhanced sexual health awareness and critical consciousness, (b) questioned their own sexual health education and challenged previous beliefs, and (c) demonstrated self-efficacy related to intended behavior change and their perceived role as social justice advocates. We present both similarities and differences regarding the sexual health change process among the college student sexual health educators across the three sites.

Pilot assessment of two disordered eating prevention programs. Preliminary findings on maladaptive beliefs related to eating disorders

AIMS

As eating disorders have severe consequences, they require prevention. We aimed to compare maladaptive beliefs related to eating disorders by following two programs based on media literacy in adolescents at post-test intervention, and after 6 and 12month-follow-ups. The Male and Female Nutrition and Media Literacy Model preventive program (NUT+MEF+MEM+ML in Spanish) and the Theater Alive program are both based on the same contents, the former being presented in a multimedia and interactive format and the latter in a drama format. Both were compared to a control group without intervention, whose participants received usual classes before the assessments.

METHOD

Participants were 178 adolescents in the second year of compulsory secondary education from fours schools of Terrassa (Catalonia, Spain). All participants in each school were assigned to the same group, depending on school schedules. A mixed 3 (group: Theater Alive, NUT+MEF+MEM+ML, control)×3 (time: post-test, 6-month-follow-up, 12-month-follow-up) factorial design was used to evaluate the effect on maladaptive beliefs measured using a CE-TCA tool.

RESULTS

When compared to the control group, both Theater Alive (d=0.88) and NUT+MEM+MEF+ML (d=0.60) obtained lower scores over time, the latter being not statistically significant.

DISCUSSION

The Theater Alive program may produce an effect of cognitive dissonance that might eliminate the discrepancy between the contents of the play and those that are internalized, thus modifying maladaptive beliefs. Participants in the Theater Alive program, as actors in front of an audience, had to defend certain content that was rehearsed over and over again to the point until it became internalized.

Motivational theater to increase consumption of vegetable dishes by preschool children

Background

By 3 years of age, many children have developed a dislike for certain foods, particularly vegetables. Seventy-five percent of young children consume less than the recommended levels for vegetables. The objective of this randomized feasibility intervention was to demonstrate the impact of an innovative approach to increase consumption of vegetable dishes by minority preschool children attending Head Start. The specific aims included the collection of data to assess feasibility and efficacy of the intervention.

Methods

Both qualitative and quantitative assessments were conducted. Qualitative data was used for development of the intervention and for program feedback at post assessments. Two hundred fifty-three preschool children (49% boys; 66% Hispanics and 34% African-Americans; mean age 4.4 years) were randomized either to the intervention (n = 128) or the control group (n = 125). The teacher/parent intervention group showed the children videotaped (DVD) puppet shows. Based on the theoretical framework “transportation into a narrative world”, three professionally developed characters, unique storylines and an engaging, repetitious song were incorporated in four 20-min DVD puppet shows. Prior to lunch each show was shown for five consecutive days in school and a minimum of once in the home. Digital photography was used in school to assess consumption of vegetable dishes at the lunch meal (quantitative assessment). At home parents were asked to complete the booklet questions corresponding to each DVD; questions could be answered correctly only if parents watched the DVD with their child. A multilevel mixed-effect model was used to analyze the data, adjusting for age, gender, and ethnicity.

Results

Children in the intervention group significantly (p < 0.0001) increased consumption of vegetable dishes from baseline to follow-up compared to no change in the control group. At follow-up, the intervention group continued to have significantly (p = 0.022) higher intake of vegetable dishes compared to the control group. Sixty percent of the mothers completed the booklet’s questions with 76 to 98% correct responses.

Conclusion

Using theory-based motivational theater with multiple exposures may be an effective behavioral intervention to increase consumption of vegetable dishes by preschool children that can be easily disseminated to a large sample.

Trial Registration

ClinicalTrials.gov; Identifier: NCT02216968

AMP!: A Cross-site Analysis of the Effects of a Theater-based Intervention on Adolescent Awareness, Attitudes, and Knowledge about HIV

AMP! (Arts-based, Multiple component, Peer-education) is an HIV intervention developed for high school adolescents. AMP! uses interactive theater-based scenarios developed by trained college undergraduates to deliver messages addressing HIV/STI prevention strategies, healthy relationships, and stigma reduction towards people living with HIV/AIDS. We used a pre-test/post-test, control group study design to simultaneously assess intervention effect on ninth grade students in an urban county in California (N = 159) and a suburban county in North Carolina (N = 317). In each location, the control group received standard health education curricula delivered by teachers; the intervention group received AMP! in addition to standard health education curricula. Structural equation modeling was used to determine intervention effects. The post-test sample was 46 % male, 90 % self-identified as heterosexual, 32 % reported receiving free or reduced lunch, and 49 % White. Structural models indicated that participation in AMP! predicted higher scores on HIV knowledge (p = 0.05), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05) at the post-test. Latent means comparison analyses revealed post-test scores were significantly higher than pre-test scores on HIV knowledge (p = 0.001), HIV awareness (p = 0.001), and HIV attitudes (p = 0.001). Further analyses indicated that scores rose for both groups, but the post-test scores of intervention participants were significantly higher than controls (HIV knowledge (p = 0.01), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05)). Thus, AMP!'s theater-based approach shows promise for addressing multiple adolescent risk factors and attitudes concerning HIV in school settings.

A Critical Review of the Characteristics of Theater-Based HIV Prevention Interventions for Adolescents in School Settings

Theater-based interventions are a viable prevention strategy for changing sexual health knowledge, attitudes, and behaviors related to HIV prevention. However, few studies have explored interventions in English-speaking, high-income countries such as the United States, Canada, or the United Kingdom. This article critically reviews the literature to identify key characteristics of theater-based HIV prevention strategies used for adolescents in school-settings in the United States, Canada, and the United Kingdom. Specifically, we identify the theatrical approach used in HIV prevention interventions, the behavioral theories that inform such interventions, and the study design and results of existing evaluation studies conducted in school settings. In the 10 articles reviewed, we found limited grounding in theory and the use of nonrigorous study design. To strengthen the evidence and practical application of theater-based HIV prevention interventions, we highlight three specific recommendations for practitioners and researchers: (1) define and operationalize the theater approach and techniques used, (2) ensure theater-based interventions are grounded in theory, and (3) conduct rigorous evaluation of theater-based interventions. These recommendations are key to strengthening future research on and implementation of theater-based interventions for HIV prevention.

Engaging adolescents in tuberculosis and clinical trial research through drama

Background

The South African Tuberculosis Vaccine Initiative is based in Worcester where tuberculosis (TB) is endemic, and incidence rates are amongst the highest nationally. In high TB burden settings after an early childhood peak, incidence rates start to rise again in adolescents, therefore they are an important target group for tuberculosis vaccine research. In 2012, learners from a local school developed a one-off theatrical production out of an educational comic book Carina’s Choice, developed by the South African Tuberculosis Vaccine Initiative in 2010. A Wellcome Trust International Engagement grant allowed for this one-off production to be further developed, with input from university students and staff, and rolled out to schools in the Worcester area as an engagement and education intervention.

Methods

Focus group feedback was used to identify key messages and to develop the play’s script. Qualitative methods were used to collect and analyse relevant data. Interviews were conducted with learner-actors, pre- and post-focus group feedback was obtained from a sample of school-going adolescents, and pre- and post-questionnaires were administered to adolescent audience members.

Results

From the pre-drama focus group discussions, topics such as TB symptoms, stigma and transmission were identified as areas that needed attention. After the performances, adolescents showed improved knowledge on the identified topics and they discussed TB prevention measures. They highlighted transmission of TB during pregnancy as a further topic to be addressed in future iterations of the drama. Although stigma is a difficult phenomenon to interpret, post-drama participants understood that TB transmission could occur in all individuals. Learner-actors agreed with focus group participants that the play could impact the wider community if it were rolled out. Feedback from the South African Tuberculosis Vaccine Initiative staff verified that recruitment for an upcoming trial was facilitated by the preparedness that the play provided in recruitment areas. The study showed that before and after evaluations provide data on the usefulness of the play as an education tool.

Conclusions

Theatre, presented and motivated by adolescent peers, can raise awareness of TB, and assist clinical trial preparedness and further engagement between trial staff and their trial community.

Effectiveness of health education teachers and school nurses teaching sexually transmitted infections/human immunodeficiency virus prevention knowledge and skills in high school

BACKGROUND

We examined the differential impact of a well-established human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) curriculum, Be Proud! Be Responsible!, when taught by school nurses and health education classroom teachers within a high school curricula.

METHODS

Group-randomized intervention study of 1357 ninth and tenth grade students in 10 schools. Twenty-seven facilitators (6 nurses, 21 teachers) provided programming; nurse-led classrooms were randomly assigned.

RESULTS

Students taught by teachers were more likely to report their instructor to be prepared, comfortable with the material, and challenged them to think about their health than students taught by a school nurse. Both groups reported significant improvements in HIV/STI/condom knowledge immediately following the intervention, compared to controls. Yet, those taught by school nurses reported significant and sustained changes (up to 12 months after intervention) in attitudes, beliefs, and efficacy, whereas those taught by health education teachers reported far fewer changes, with sustained improvement in condom knowledge only.

CONCLUSIONS

Both classroom teachers and school nurses are effective in conveying reproductive health information to high school students; however, teaching the technical (eg, condom use) and interpersonal (eg, negotiation) skills needed to reduce high-risk sexual behavior may require a unique set of skills and experiences that health education teachers may not typically have.

Assessment of two school-based programs to prevent universal eating disorders: media literacy and theatre-based methodology in Spanish adolescent boys and girls

AIMS

To evaluate the long-term effects of two school-based prevention programs administered to a universal mixed-sex sample of school-going adolescents on disturbed eating attitudes, aesthetic ideal internalization, and other eating disorder risk factors, when compared to a control group.

METHODS

Participants were 200 adolescents aged 12-15 selected by means of incidental sampling from second-year compulsory secondary education at schools. An interactive multimedia media literacy program (ML + NUT, Media Literacy and Nutrition) and a program focused on the same topics using dramatic arts (Theatre Alive) were applied and compared with a control group. Pretest, posttest (1 month later), and 5- and 13-month follow-up measurements were taken. Analyses were conducted with two-way mixed 3 × 3 ANCOVA (group × phase) adjusted by baseline levels, body mass index, and sex.

RESULTS

Participants in both experimental groups showed significantly higher self-esteem scores than the control group over time. The ML + NUT group also presented lower aesthetic ideal internalization scores than the control group.

DISCUSSION

Both programs can benefit students' self-esteem. Moreover, ML + NUT program was useful in reducing thin-ideal internalization. However, differences in body dissatisfaction and disordered eating attitudes were not found. The programs may be protective on the core psychological variables, which are essential to adaptive adolescent development.

The Healthy Lifestyles Programme (HeLP)--an overview of and recommendations arising from the conceptualisation and development of an innovative approach to promoting healthy lifestyles for children and their families

Despite the rise in childhood obesity, there remains a paucity of evidence for effective interventions that engage children and parents sufficiently to make and sustain lifestyle behaviour change. The Healthy Lifestyles Programme (HeLP) is a school-located obesity prevention programme, which has been developed with teachers, families and healthcare professionals. The underpinning assumption in the development of HeLP was to take a relational approach to changing behaviour, building relationships with the schools, children and their families to create supportive environments for healthy lifestyle choices. Thus, HeLP was conceptualised as a complex intervention within a complex system and developed as a dynamic, evolving set of processes to support and motivate children towards healthy behaviours. The delivery methods used are highly interactive and encourage identification with and ownership of the healthy lifestyle messages so that the children are motivated to take them home to their parents and effect change within the family. We have good evidence that HeLP engages schools and children such that they want to participate in the Programme. Results from an exploratory trial showed that the Programme is feasible and acceptable and has the potential to change behaviours and affect weight status. This paper presents an overview of and recommendations arising from the conceptualization; development and evaluation of the Healthy Lifestyles Programme as part of a special issue focusing on novel approaches to the global problem of childhood obesity.

'I learned to be okay with talking about sex and safety': assessing the efficacy of a theatre-based HIV prevention approach for adolescents in North Carolina

Adolescents are at increased risk of HIV and sexually transmitted infections (STIs) in the Southern states of the USA, where rates among youth are higher than in the rest of the nation. This paper reports on findings from a pilot study of an HIV prevention intervention that uses interactive theatre to educate young people about sexual health. The intervention was developed in Los Angeles and adapted for testing in the South of the USA, with its legacy of abstinence-based approaches to sexual health education. This study assessed intervention effects among a sample of young people in two public high schools in North Carolina. We used a pre-test, post-test quasi-experimental evaluation design to assess changes in 317 ninth grade participants' knowledge and attitudes about HIV. At post-test, we found statistically significant increases in participants' HIV knowledge (t= 60.14; p=.001), as well as changes in attitudes (X² =8.23; p=.042) and awareness (X² =4.94; p=.026). Focus group data corroborated increase in HIV knowledge and reduction in HIV stigma as successful outcomes of intervention participation. The findings make an important contribution to the literature on theatre-based interventions for sexual health education. Furthermore, they highlight the importance of considering socio-cultural and political context in implementing HIV prevention interventions in schools.

Qualitative findings from an exploratory trial of the Healthy Lifestyles Programme (HeLP) and their implications for the process evaluation in the definitive trial

BACKGROUND

Approximately one third of 10-11 year olds in England are now overweight or obese suggesting that population approaches are urgently required. However, despite the increasing number of school-based interventions to prevent obesity, results continue to be inconsistent and it is still unclear what the necessary conditions are that lead to the sustained behaviour change required to affect weight status. The Healthy Lifestyles Programme is a theoretically informed four phase multi-component intervention which seeks to create supportive school and home environments for healthy behaviours.

METHODS

A process evaluation has run alongside the exploratory trial of the Healthy Lifestyles Programme to ascertain the feasibility and acceptability of; the trial design (including the trial outcomes) and the HeLP Programme and whether it is able to engage schools, children and their families. Data was collected using interviews with teachers (n = 12) and parents (n = 17) and six focus groups with children (n = 47) and a questionnaire for parents of children in the intervention schools. Interview and focus group data relating to the intervention was analysed using framework analysis.

RESULTS

Four schools and 201 children participated in the exploratory trial. The data showed that the trial design was feasible and acceptable for schools and children. Three themes emerged for the data in relation to the acceptability and feasibility of the HeLP Programme (value, compatibility with the curriculum and enjoyment) and two themes emerged in relation to engagement ('knowledge and awareness' and 'taking messages on board'). The latter could be broken down into 4 subthemes ('initiating discussion with family and friends', 'acceptance of family rules', 'increased responsibility' and 'the importance of the mode and agent of delivery'). The use of highly inclusive and interactive delivery methods where the children were encouraged to identify with and take ownership of the healthy lifestyle messages were identified as important factors in motivating the children to take the messages home, seek parental support and initiate family lifestyle behaviour change.

CONCLUSION

The process evaluation of the exploratory trial has not only provided evidence of the feasibility and acceptability of the Programme, it has also allowed an understanding of how HeLP engages schools, children and their families. These findings have informed the process evaluation for the definitive trial.

Sun protection training based on a theater play for preschoolers: an effective method for imparting knowledge on sun protection?

Sun protection in childhood is important to reduce the risk of developing skin cancer later in life. The "Periods-of-Life-Program" for primary prevention of skin cancer introduces a combination of individual and environmental interventions for the preschool period. Within this pilot study, an intervention group received cognitive-behavioral and environmental interventions. A control group had solely received the environmental intervention, and a wait-control group received no intervention. Nursery school children (n = 80, 3 to 6 years of age) of four nursery schools were randomly assigned to these groups on school level. The ability of the cognitive-behavioral intervention (a theater play) to enhance sun protection knowledge was examined. The theater play improved knowledge over all age groups (p < .05 η(2) = .06). Age-specific analyses showed better results for children aged 5 to 6 (p < .05 η(2) = .20) compared to children aged 3 to 4 years (p = .17 η(2) = .04). In combining cognitive-behavioral and environmental interventions, the "Periods-of-Life-Program" is a promising strategy for primary prevention of skin cancer.

Engaging youth in learning about healthful eating and active living: an evaluation of Educational Theater Programs

OBJECTIVE

To compare knowledge gains and knowledge retention of healthful eating and active living behaviors in elementary school children participating in Educational Theatre Programs (ETP).

METHODS

The study sample included 47 schools (2,915 third- or fourth-grade students) in 8 Kaiser Permanente regions. Children's knowledge of 4 healthful behaviors was measured using a brief survey before and immediately after performances, followed by a post-delay survey 3 weeks later.

RESULTS

Statistically significant increases in knowledge pre/post for individual topics (P < .01). The percentage of children who answered all 4 questions correctly increased from 17% to 63% immediately after ETP performances (P < .01). Knowledge was retained over the short term; the proportion of students who correctly identified recommended healthful eating/active living practices had declined only slightly 3 weeks later.

CONCLUSIONS AND IMPLICATIONS

The ETP significantly improved participating students' knowledge of healthful eating and active living concepts. Theater programs should be considered for inclusion in elementary school health curricula.

An evaluation of a drama program to enhance social relationships and anti-bullying at elementary school: a controlled study

Drama, theater and role-playing methods are commonly used in health promotion programs, but evidence of their effectiveness is limited. This paper describes the development, implementation and evaluation of a school-based drama program to enhance social relationships and decrease bullying at school in children in grades 4-5 (mean age of 10.4 years). Students (n = 190) were recruited from two primary schools with similar demographics and socio-economics in the Southern Finland and purposively allocated either to an intervention group or a control group. The drama program included classroom drama sessions, follow-up activities at home and three parents' evenings concerning issues of social well being during the school year September 2007-May 2008. Data on social relationships in the class room and experiences of bullying were obtained before and after the program using self-completed questionnaire from the same students (n = 134). The response rate was 71%. No differences in socio-demographics existed between intervention group and control group at pretest. The positive effect on social relationships resulting from the intervention approached statistical significance (p = 0.065). Moreover, the positive effect was found to be statistically significant in the high-intensity intervention classes (p = 0.011). Bullying victimization decreased 20.7 percentage units from pretest (58.8%) to posttest (38.1%) in the intervention group (p < 0.05). The study indicates that using applied drama and theater methods in the classroom may improve children's social relationships at school.

Family nursing research for practice: the Finnish perspective

This article summarizes the efforts of the Department of Nursing Science, University of Tampere, Finland, to advance knowledge about family nursing over the past 15 years. Definitions of family, family nursing, and family nursing science are offered. Programs of research include families' experiences of care received in health care settings, family violence and child maltreatment, and the psychometric development of instruments to assess family functioning and family health. Research is currently examining the effectiveness of family nursing interventions. Recommendations are offered to strengthen collaboration between family nursing researchers, educators, and practitioners at the local level and initiate greater collaboration between family researchers at the interdisciplinary and international levels.

The role of behavioral science theory in development and implementation of public health interventions

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Can arts projects improve young people's wellbeing? A social capital approach

Community arts projects are widely believed to have positive impacts on health, wellbeing and social inclusion. Such beliefs underpinned the UK Government-funded SingUp programme for children. Drawing on data from participant observation, extended interviews, focus groups and a questionnaire survey, we examine the experiences of children in three SingUp choirs. We focus specifically on social and emotional wellbeing as they relate to social capital: this being one of the key pathways through which arts participation is thought to impact on health and wellbeing more widely. For many (particularly girls from relatively privileged backgrounds), the experience has been largely positive, providing opportunities to develop social capital, make new friends and build confidence. However, others' experiences have been more equivocal, entailing risks of disconnection from existing networks of friends. We argue that, while arts projects can impact positively on young people's social and emotional wellbeing, we cannot assume that the changes will be unequivocally good or straightforward. We follow Bourdieu and other critical theorists in arguing that social capital operates in association with economic and cultural capital, and cannot be understood in isolation from the wider constraints of people's lives.