School-based programs for health-risk reduction

Primary prevention of ischaemic heart disease: populations, individuals, and health professionals

Ischaemic heart disease has a multifactorial aetiology and can be prevented from developing in populations primordially, and in individuals at high risk by primary prevention. The primordial approach focuses on social determinants of health in populations: political, economic, and social factors, principally unplanned urbanisation, illiteracy, poverty, and working and living conditions. Implementation of the UN Sustainable Development Goals can lead to major improvements in cardiovascular health, and adequate health-care financing and universal health care are important for achieving these goals. Population-level interventions should focus on tobacco control, promotion of healthy foods (fruits, vegetables, legumes, and nuts), curbing unhealthy foods (saturated fats, trans fats, refined carbohydrates, excessive salt, and alcohol), promotion of physical activity in everyday living, and control of ambient and indoor pollution. At the individual level, identification of people at high multifactorial risk and guideline-driven management of hypertension, LDL cholesterol, and diabetes is required. Strategies to improve adherence to healthy lifestyles and drug therapies are essential and can be implemented at health system, health care, and patient levels with use of education, technology, and personalised approaches. Improving quality of medical education with a focus on ischaemic heart disease prevention for physicians, nurses, allied health workers, and the public is required.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Effects of the Young Adolescent Sleep Smart Program on sleep hygiene practices, sleep health efficacy, and behavioral well-being

OBJECTIVES

Using a social learning model, the aim of the Sleep Smart Program was to primarily improve sleep health behaviors and secondarily improve academic performance and behavioral well-being.

DESIGN

Randomized control trial for a social learning-based preventive intervention program.

PARTICIPANTS

A diverse group of seventh graders from 2 urban, middle schools were randomly assigned, according to school, to an 8-session Sleep Smart Program (SS = 70) or a comparison group (comparison = 73).

MEASUREMENTS

Sleep patterns, sleep hygiene, and sleep health efficacy; academic performance; and behavioral well-being were assessed at 4 times of measure (baseline, postintervention, 2 follow-up times in eighth grade).

RESULTS

SS seventh graders experienced significantly greater sleep health efficacy, improved physiological and emotional sleep hygiene, more time in bed, and earlier bedtimes vs comparison group. SS (vs comparison) participants also reported a significant decrease in internalizing behavior problems and sustained academic performance. Finally, although not maintained at time 4, SS participants continued to report improved sleep health efficacy at time 3, whereas the comparison group participants' sleep health efficacy declined.

CONCLUSION

The Sleep Smart preventive intervention was effective in improving sleep health efficacy, sleep hygiene, time in bed, and bedtimes; in maintaining grades; and in reducing internalizing behavior problems, yet these changes were not sustained at follow-up.

Increased risk for coronary vascular disease in children with developmental coordination disorder

PURPOSE

Physical activity (PA) is compromised in children and adolescents with Developmental Coordination Disorder (DCD). The purpose of this study was to test a theoretical model linking DCD with 2 factors associated with increased risk for coronary vascular disease: (1) cardio-respiratory fitness (CF), and (2) relative body fat (BF), through physical activity.

METHODS

A cross-sectional design was implemented using 571 elementary school students (313 males, 258 females). Evaluation of body fat using bioelectric impedance, cardio-respiratory fitness using Léger 20-meter Shuttle Run, and physical activity level was determined using the Participation Questionnaire. The short-form version Bruininks-Oseretsky Test of Motor Proficiency was used to verify DCD. We tested to see how much of the association between DCD and factors associated with increased risk for coronary vascular disease (percentage body fat and cardio-respiratory fitness) using multivariate ordinary least squares regression analysis.

RESULTS

Regression modeling demonstrated that DCD was associated with increased body fat and low cardio-respiratory fitness. Physical activity was a significant mediator in the DCD-CF relationship. Physical activity was also a mediating factor in the DCD-BF relationship, albeit to a lesser extent.

CONCLUSIONS

Developmental coordination disorder is related with factors associated with increased risk for coronary vascular disease, including decreased cardio-respiratory fitness and increased body fat through the mediating influence of physical activity in children.

Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years

It is the position of the American Dietetic Association that children ages 2 to 11 years should achieve optimal physical and cognitive development, attain a healthy weight, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. The health status of American children has generally improved over the past three decades. However, the number of children who are overweight has more than doubled among 2- to 5-year-old children and more than tripled among 6- to 11-year-old children, which has major health consequences. This increase in childhood overweight has broadened the focus of dietary guidance to address children's over consumption of energy-dense, nutrient-poor foods and beverages and physical activity patterns. Health promotion will help reduce diet-related risks of chronic degenerative diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This position paper reviews what US children are eating and explores trends in food and nutrient intakes as well as the impact of school meals on children's diets. Dietary recommendations and guidelines and the benefits of physical activity are also discussed. The roles of parents and caregivers in influencing the development of healthy eating behaviors are highlighted. The American Dietetic Association works with other allied health and food industry professionals to translate dietary recommendations and guidelines into achievable, healthful messages. Specific recommendations to improve the nutritional well-being of children are provided for dietetics professionals, parents, and caregivers.

Methodologic advances and ongoing challenges in designing community-based health promotion programs

Community intervention trials continue to attract researchers as potential ways to achieve widespread, long-term change in health behaviors. The first generations of community studies were somewhat unsophisticated in design and analysis, and their promise may have been overstated. As design and analysis issues were better defined, as secular trends caught up with the behaviors that researchers were trying to change, or as other unknown variables affected community studies, small effects of interventions were observed in community trials. Discussions were held in professional meetings and reported in the literature: Should community trials be discontinued? In general, the answer was a qualified no. In this paper, we briefly review some of the many advances made in community intervention trials, and address in more detail the challenges ahead.

The HeartSmart Family Fun Pack: an evaluation of family-based intervention for cardiovascular risk reduction in children

In 1998, the Heart and Stroke Foundation launched the HeartSmart Family Fun Pack, a "user-friendly" resource to support family-based lifestyle changes among children age 6-12 years. Of 1,387 parents who completed a pre-intervention questionnaire, 300 (21%) were surveyed three months later. Comparisons of the pre- and post-intervention surveys show that the Family Fun Pack was effective in supporting healthy lifestyle changes (38% and 28% of families reported improvement in their child's nutrition and level of physical activity, respectively; 12% reported reduced passive smoking). Effectiveness was greatest among those families who self-identified themselves as being in what corresponds to the contemplation, preparation and action stages of change. This evaluation suggests that a relatively low-cost intervention can be effective in supporting positive lifestyle changes if targeted to families at specific points in the stages of change.