Obesity prevention and the Health promoting Schools framework: essential components and barriers to success

Qualitative multi-stakeholder evaluation of the adoption, implementation and sustainment of the school-based dietary intervention "Jump-in"

BACKGROUND

Comprehensive school-based programs applying the WHO Health Promoting School Model have the potential to initiate and sustain behavior change and impact health. However, since they often include intervention efforts on a school's policies, physical environment, curriculum, health care and involving parents and communities, they significantly 'intrude' on a complex system that is aimed primarily at education, not health promotion. More insights into and concrete strategies are therefore needed regarding their adoption, implementation, and sustainment processes to address the challenge to sustainable implementation of HPS initiatives in a primarily educational setting. This study consequently evaluates adoption, implementation and sustainment processes of Amsterdam's Jump-in healthy nutrition HPS intervention from a multi-stakeholder perspective.

METHODS

We conducted semi-structured interviews and focus groups with all involved stakeholders (n = 131), i.e., Jump-in health promotion professionals (n = 5), school principals (n = 7), at-school Jump-in coordinators (n = 7), teachers (n = 20), parents (n = 50, 9 groups) and children (n = 42, 7 groups) from 10 primary schools that enrolled in Jump-in in the school year 2016-2017. Included schools had a higher prevalence of overweight and/or obesity than the Dutch average and they were all located in Amsterdam's low-SEP neighborhoods. Data were analyzed using a directed content analysis, in which the Determinants of Innovation Model was used for obtaining theory-based predetermined codes, supplemented with new codes emerging from the data.

RESULTS

During intervention adoption, all stakeholders emphasized the importance of parental support, and accompanying workshops and promotional materials. Additionally, parents and teachers indicated that a shared responsibility for children's health and nuanced framing of health messages were important. During implementation, all stakeholders needed clear guidelines and support structures. Teachers and children highlighted the importance of peer influence, social norms, and uniform application of guidelines. School staff also found further tailoring of the intervention and dealing with financial constraints important. For long-term intervention sustainment, incorporating the intervention policies into the school statutes was crucial according to health promotion professionals.

CONCLUSIONS

This qualitative evaluation provides valuable insights into factors influencing the adoption, implementation, and sustainment processes of dietary interventions, such as the importance of transparent and consistent intervention guidelines, clear communication regarding the rationale behind intervention guidelines, and, stakeholders' involvement in decision-making.

Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial

BACKGROUND

High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)].

METHODS

This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors.

RESULTS

Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001).

CONCLUSIONS

Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline.

TRIAL REGISTRATION

Clincialtrials.gov: NCT03740113. Registered 14 November 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113 .

Promoting hEalthy Diet and Active Lifestyle (PEDAL): a protocol for the development and feasibility study of a multicomponent intervention among primary school children in Singapore

BACKGROUND

Setting healthy lifestyle habits during the formative years of childhood is critical as habits can track to adulthood and help prevent obesity and chronic disease risks in later life. While multicomponent interventions have been shown to be effective in changing the lifestyle behaviours of children, there is a limited understanding of the feasibility of such interventions in primary schools in Singapore. A multiphase mixed method study was conducted to develop and examine the feasibility of a theory-based multicomponent school-based intervention-Promoting hEatlthy Eating and Active Lifestyle (PEDAL).

METHODS

Underpinned by Kincaid's ideation model, the PEDAL intervention was developed to increase fruit and vegetable consumption and decrease sedentary behaviours among children. This study consists of three phases. Phase 1 details the development of PEDAL, which consists of four components: (A) a series of interactive health education lessons, (B) actionable home activities to support habit formation, (C) parental/guardian engagement, and (D) optimising the school environment. In Phase 2, components A and B of PEDAL were implemented in two public, co-educational primary schools among Primary 5 students (aged 10-12 years) in Singapore. Data was collected quantitatively using questionnaires and qualitatively using focus group discussions (FGDs) with students and teachers. The feasibility dimensions of components A and B, including recruitment capability, data collection, social validity, and practicality were examined, and ideation on healthy eating and physical activity was explored. In Phase 3, the full PEDAL intervention was pilot-tested in two other public, co-education primary schools with the same target population, using a concurrent mixed method quasi-experimental study design. Feasibility dimensions and potential effectiveness of the intervention will be assessed.

DISCUSSION

This study will provide insights into the feasibility of PEDAL and inform its refinement. Findings from the pilot test will guide the planning of a larger-scale definitive trial.

TRIAL REGISTRATION

Registered with ISRCTN registry (ISRCTN16114046) on 16 October 2022.

Examining associations between school-level determinants and the implementation of physical activity opportunities

School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (β = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (β = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.

School-based interventions TO Prevent Dating and Relationship Violence and Gender-Based Violence: STOP-DRV-GBV systematic review

Background

Schools have a duty of care to prevent violence between students but a significant amount of dating and relationship violence and gender-based violence occurs in schools. These are important public health issues with important longitudinal consequences for young people.

Objectives

To understand functioning and effectiveness of school-based interventions for the prevention of dating and relationship violence and gender-based violence.

Review methods

We undertook a mixed-methods systematic review to synthesise different types of evidence relating to school-based interventions for the prevention of dating and relationship violence and gender-based violence to understand if, how and in what ways these interventions are effective. We searched 21 databases and 2 trial registers and undertook forwards and backwards citation chasing, author contact and other supplementary search methods. Searches identified all literature published to June 2021. All screening was undertaken in duplicate and independently, and we quality appraised all included studies.

Results

We included 247 reports (68 outcome evaluations, 137 process evaluations). Synthesis of intervention components produced an intervention typology: single-component, curricular, multicomponent, and multilevel programmes. Synthesis of intervention theories suggested that interventions aiming to increase students' sense of school belonging and sense of safety in the school building could encourage increased learning of prosocial skills and increased prosocial peer norms, and so potentially reducing dating and relationship violence and gender-based violence. Synthesis of factors affecting delivery highlighted school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important. Meta-analysis found stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration, and some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. Impacts on knowledge and attitudes were primarily short-term. Network meta-analysis did not suggest superiority of any intervention type. Moderation evidence suggested interventions reduced dating and relationship violence perpetration in boys more than girls, but reduced gender-based violence perpetration more in girls. Metaregression by intervention component did not explain heterogeneity in effectiveness, but qualitative comparative analysis suggested that reducing perpetration was important to reducing victimisation, and that perpetration could be reduced via focus on interpersonal skills, guided practice and (for gender-based violence) implementation of social structural components.

Limitations

Despite an exhaustive search, trials may have been missed and risk of publication bias was high for several analyses.

Conclusions

This is the most comprehensive systematic review of school-based interventions for dating and relationship violence and gender-based violence to date. It is clear that the prevention of dating and relationship violence and gender-based violence in schools will require longer-term investment to show benefit.

Future work

Future research is needed to understand why intervention effectiveness appears stronger for dating and relationship violence than gender-based violence.

Study registration

The study is registered as PROSPERO CRD42020190463.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR130144) and is published in full in Public Health Research; Vol. 12, No. 3. See the NIHR Funding and Awards website for further award information.

Cost-effectiveness of dental caries prevention strategies in South African schools

BACKGROUND

In South Africa, an estimated 85% of the population relies on the public sector for oral health services. With poor infrastructure and inadequate personnel, over 80% of children with dental caries remain untreated. To reduce this burden of disease, one key goal is to promote good oral health and address oral diseases through prevention, screening, and treatment among children. While all policies have been proven to be effective in the control and prevention of dental caries, it is unclear which of those strategies provide value for money. This study evaluated five caries preventative strategies in terms of the cost and benefits among South African school children.

METHODS

The study uses a hypothetical South African population of school aged learners aged 5-15. The context and insights of the strategies utilized at the schools were informed by data from both grey and published literature. Using Markov modeling techniques, we conducted a cost-effectiveness analysis of Acidulated Phosphate Fluoride (APF) application, atraumatic restorative treatment (ART), sugar-reduction and fissure sealants. Markov model was used to depict the movement of a hypothetical patient cohort between different health states over time. We assessed both health outcomes and costs of various interventions. The health outcome metric was measured as the number of Decayed, Missing, Filled Tooth (DMFT). The net monetary benefit was then used to determine which intervention was most cost-effective.

RESULTS

The results showed that school-based caries prevention strategies are cost-effective compared to the status quo of doing nothing. The average cost per learner over the 10-year period ranged from ZAR4380 to approx. ZAR7300 for the interventions considered. The total costs (including screening) associated with the interventions and health outcome (DMFT averted) were: sugar reduction (ZAR91,380, DFMT: 63,762), APF-Gel (ZAR54 million, DMFT: 42,010), tooth brushing (ZAR72.8 million, DMFT: 74,018), fissure sealant (ZAR44.63 million, DMFT: 100,024), and ART (ZAR45 million, DMFT: 144,035). The net monetary benefits achieved for APF-Gel, sugar reduction, tooth brushing, fissure sealant and ART programs were ZAR1.56, ZAR2.45, ZAR2.78, ZAR3.81, and ZAR5.55 billion, respectively.

CONCLUSION

Based on the net monetary benefit, ART, fissure sealant and sugar-reduction appear to be the most cost-effective strategies for preventing caries in South Africa. In a resource-scarce setting such as South Africa, where there is no fluoridation of drinking water, this analysis can inform decisions about service packages for oral health.

Teaching Australian high school students to think critically about health claims: a cluster randomized trial

Making informed health decisions requires knowledge and skills in appraising health claims, and teaching adolescents these skills may prepare them for future decision-making. This cluster randomized trial evaluated the effectiveness of an educational intervention on students' ability to identify and appraise health claims. Nine Australian high schools (4 control and 5 intervention) were recruited, comprising 974 students (382 control and 592 intervention) in Grades 7-10. Intervention impact was evaluated through baseline and follow-up evaluation. Follow-up mean scores on questions (maximum score of 25) from the Claim Evaluation Tools database (primary outcome) showed minimal between-group difference (intervention versus control: 14.4 versus 13.6; difference 0.8, 95% confidence interval [CI] -1.6 to 3.1; P = 0.52). Change scores were only slightly higher in the intervention group (difference 1.2 [95% CI -0.7 to 3.1; P = 0.21]). Between-group differences for secondary outcomes were also minimal. Most intervention group students 'trusted' and 'liked' the programme and found the content 'easy' and 'helpful'. Most teacher feedback was positive, some noting challenges of covering content in allocated time and maintaining student engagement. It is unlikely that the assessed educational intervention had a large effect. Future research priorities are suggested.

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.

Parents' experiences of participating in the Healthy School Start Plus programme - a qualitative study

BACKGROUND

The rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children's lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents' experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study.

METHODS

HSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Parental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff.

CONCLUSIONS

Barriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents' abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important.

TRIAL REGISTRATION

The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Improving adolescents' dietary behaviours in the school-setting: challenges and opportunities

Adolescence is a critical time of physical, psychological and social development, and thus, optimal nutritional intakes are required during this life stage. Despite this, adolescence is recognised as a period of nutritional vulnerability, with many reportedly failing to meet current dietary guidelines. The school-setting presents a favourable environment to intervene and promote positive dietary behaviours and is also inclusive regardless of socio-economic status. However, a lack of consensus exists on how best to utilise schools to facilitate improvements in dietary behaviours among this age group. Whilst previous research has focused on identifying the factors motivating dietary choices within the school-setting, less is known on the optimum strategies to enhance these dietary choices which could positively contribute to the design of future interventions. It is reported that adolescents have good nutritional knowledge, although this does not appear to be a central consideration when making their dietary choices. Alternative factors at the individual (taste, visual appeal, familiarity, food quality, price, portion size, value for money, time/ convenience), social (peer influence), physical (product placement) and macro environment (food availability) levels have been frequently cited as important influences on adolescents' dietary choices in school. Although school-based interventions have shown potential in achieving positive dietary change among adolescents, more research is needed to determine the most effective methods in improving dietary behaviours in schools. This review summarises the key factors which influence adolescents' school-based dietary choices and the effectiveness of previously conducted interventions, identifying promising components for consideration when developing future dietary interventions within the school-setting.

Barriers and enablers to the implementation of school-based obesity prevention strategies in Jeddah, KSA

Introduction

Despite schools' recognised role in mitigating childhood overweight, many schools fail to implement physical activity or nutrition strategies. The current study explored the enablers and barriers to implementing obesity prevention strategies in Jeddah, KSA.

Methods

This research is based on 14 semi-structured interviews with intermediate school principals and sports teachers to gain insight into their perception of barriers and enablers to implementing obesity prevention strategies. Themes were deductively generated from the data.

Results

Participants estimated the prevalence of overweight and obesity among their students to be between 3 and 15% with an increasing trend, particularly among female students. Participants identified five categories of barriers to implementation of obesity prevention intervention: curriculum; schools strategies promoting healthy weight; lack of resources; student’s lifstyle; and a lack of teachers in nutrition and sports. School regulations, staff and sufficient resources were the most frequently reported enablers. Participants also identified food services, awareness, and partnerships as barriers and enablers.

Conclusion

There is a need for better infrastructure and financial support for schools and professional development opportunities for teachers from the Saudi Ministry of Education. The Ministry also needs to support the development of multilevel health promotion strategies at school and home and reach out to the broader community.

An evaluation of the 'bottom-up' implementation of the Active at school! programme in Quebec, Canada

The lack of physical activity (PA) amongst children is a public health concern in many industrialized countries. School-based daily physical activity (DPA) policies are a promising intervention for increasing PA levels amongst children. Informed by a logic model framework, this study examines the factors associated with meeting a 'top-down' DPA objective in the context of a 'bottom-up' implementation of a school-based DPA initiative in Quebec, Canada. An online survey assessing school-level inputs, outputs and outcomes was sent to all participating schools (415). Crude odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression to evaluate potential associations between factors (inputs and outputs) and the school's adherence to providing at least 60 minutes of DPA (outcome). Adjusted ORs (AORs) and 95% CIs were calculated using a multivariate logistic regression to identify the best set of factors to predict adherence to the DPA objective. A total of 404 schools completed the questionnaire, amongst which 71% reported meeting the DPA target by implementing school-tailored activities. Three factors were identified as the best set of school inputs and outputs to predict meeting the objective: financial resources (per student) (AOR = 1.02; 95% CI 1.01-1.03), a shared vision amongst the school-team members that PA benefits learning outcomes (AOR = 1.94; 95% CI 1.04-3.19) and having conducted a detailed situational analysis (AOR = 1.89; 95% CI 1.00-3.58). Given that 'bottom-up' implementation might favour the development of policies that are more acceptable to stakeholders, our results should be considered by decision-makers and school administrators when implementing DPA initiatives.

The Impact of Modifying Food Service Practices in Secondary Schools Providing a Routine Meal Service on Student's Food Behaviours, Health and Dining Experience: A Systematic Review and Meta-Analysis

The education sector is recognised as an ideal platform to promote good nutrition and decision making around food and eating. Examining adolescents in this setting is important because of the unique features of adolescence compared to younger childhood. This systematic review and meta-analysis examine interventions in secondary schools that provide a routine meal service and the impact on adolescents’ food behaviours, health and dining experience in this setting. The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and Cochrane Handbook recommendations. Studies published in English searched in four databases and a hand search yielded 42 interventions in 35 studies. Risk of bias was assessed independently by two reviewers. Interventions were classified using the NOURISHING framework, and their impact analysed using meta-analysis, vote-counting synthesis or narrative summary. The meta-analysis showed an improvement in students selecting vegetables (odds ratio (OR): 1.39; 1.12 to 1.23; p = 0.002), fruit serves selected (mean difference (MD): 0.09; 0.09 to 0.09; p < 0.001) and consumed (MD: 0.10; 0.04 to 0.15; p < 0.001), and vegetable serves consumed (MD: 0.06; 0.01 to 0.10; p = 0.024). Vote-counting showed a positive impact for most interventions that measured selection (15 of 25; 41% to 77%; p = 0.002) and consumption (14 of 24; 39% to 76%; p = 0.013) of a meal component. Interventions that integrate improving menu quality, assess palatability, accessibility of healthier options, and student engagement can enhance success. These results should be interpreted with caution as most studies were not methodologically strong and at higher risk of bias. There is a need for higher quality pragmatic trials, strategies to build and measure sustained change, and evaluation of end-user attitudes and perceptions towards intervention components and implementation for greater insight into intervention success and future directions (PROSPERO registration: CRD42020167133).

Motivating Social Influencers to Engage in Health Behavior Interventions

Social influencers are widely known as the promotors of purchase behavior as well as for their potential to change health behaviors among individuals in their social networks. For social influencers to be successful in changing behaviors, it is essential that they convey their message in an authentic, original, credible, and persistent manner. In the context of health behavior interventions, this requires a focus on the motivation of social influencers to engage in the intervention. This perspective article describes the importance of motivating social influencers to engage in the desired health behaviors themselves and to promote it within their social network. We briefly describe the current state of knowledge and our empirical experience in implementing health interventions with social influencers. Using insights from self-determination theory, we demonstrate how social influencers can be motivated optimally in health behavior interventions and, thereby, improving the success of the intervention. To illustrate these insights and guide intervention practice, we provide concrete examples of techniques that can be applied in health interventions involving social influencers. We conclude with directions for further research and intervention practice to improve the delivery of health behavior interventions.

Interventions for Health and Well-Being in School-Aged Children and Adolescents: A Way Forward

The health and well-being of school-aged children has received little attention compared with younger children aged < 5 years and adolescents. In this final article in a supplement of reviews that have assessed the effectiveness of interventions for school-aged children across a variety of health-related domains (including infectious diseases, noncommunicable diseases, healthy lifestyle, mental health, unintentional injuries, and sexual and reproductive health), we summarize the main findings and offer a way forward for future research, policy, and implementation. We complement this evidence base on interventions with a summary of the literature related to enabling policies and intersectoral actions supporting school-aged child health. The school represents an important platform for both the delivery of preventive interventions and the collection of data related to child health and academic achievement, and several frameworks exist that help to facilitate the creation of a health-promoting environment at school.

What are the environmental factors that affect implementation of the Manchester Healthy Schools programme? A qualitative exploration of staff perspectives

OBJECTIVES

Primary/elementary schools are crucial settings for early weight management interventions but effects on children's weight are small. This may be because the environments in which these schools are situated support unhealthy behaviours that lead to weight gain (obesogenic environments). Staff working in schools have a unique insight into the environmental factors that might affect their efforts to support child health and weight management interventions. The aim of this study is to explore the views of staff in relation to the perceived effects of the environmental context in which they deliver a child health promotion intervention.

METHODS

Staff from five schools involved in delivering the Manchester Healthy Schools programme were interviewed (N=19). These interviews were transcribed verbatim and analysed thematically.

RESULTS

Three themes were produced: opportunities to be healthy; importance of funding, resources and governance; and resources available to households and neighbourhoods.

CONCLUSION

The views of school staff were consistent with themes identified in other relevant literature. Although there were serendipitous opportunities to capitalise on local resources, such as using nearby land and leisure facilities for outdoor physical activities, many barriers relating to local environmental and resource features were reported. Joined up, multi-agency solutions such as place-based approaches might be able to offer schools some resource-based support; however, more research is needed to establish the best way to achieve the best outcomes for children.

Using Co-Design to Develop a Health Literacy Intervention with Socially Disadvantaged Adolescents

The aim of this study was to initiate a co-design process with adolescents to inform the development of a targeted health literacy intervention for implementation in designated socioeconomically disadvantaged post-primary schools in Ireland. Purposely developed vignettes were explored in a series of eight workshops that were conducted separately with staff (n = 26) and students (n = 33) across four schools. Data was analysed using content analysis. A number of key health topics were identified as important and influential for the participants in this context: food choices, mental health and wellbeing, physical activity and sedentary behaviour, sleep and substance misuse. Participants also suggested many health-related capacity building actions. Participants recognized that many of these health topics and capacity building actions were intertwined and also highlighted that some of these actions may be more feasible and/or impactful than others. For example, students and school staff both indicated the need to use relevant, applied and engaging approaches to improve health literacy and subsequent health behaviour. The co-design process adopted empowered stakeholders to actively engage in the design and development of future intervention strategies, which may increase the likelihood of acceptability, effectiveness and sustainability of the resulting intervention.

Evaluating an integrated nutrition and mathematics curriculum: primary school teachers' and students' experiences

OBJECTIVE

To present the process evaluation of a curricular Cross-curricular Unit on Portion Size (CUPS) program that integrates nutrition and mathematics, describing teacher and student perspectives on the intervention.

DESIGN

Semi-structured interviews and focus groups were conducted following the implementation of the CUPS program during a pilot randomised controlled trial designed to evaluate efficacy for improved portion size estimation. Lessons involved experiential learning using food models and mathematics cubes and focussed on portion size, food groups, volume and capacity. Data were collected immediately post-intervention and analysed using an inductive thematic approach.

SETTING

Primary schools in Newcastle, Australia.

PARTICIPANTS

Year 3 and/or 4 teachers (n 3) and their students (n 15).

RESULTS

Teachers believed the programme supported the learning of nutrition concepts, with the majority of students enjoying the lessons, cubes and food models. Teachers indicated most students were engaged and became more aware of healthy eating and serve size recommendation. Although teachers enjoyed and valued the lessons, they suggested that the integration of volume and capacity should be further improved in order to address the time barrier for teaching nutrition.

CONCLUSION

The process evaluation reports on challenges and successes of implementing an integrative nutrition programme. This teaching approach could be useful and successful when aligned with teacher' and student' needs. Based on participant feedback, lessons could be refined to enhance integration of mathematics content and to support student learning.

Barriers and facilitators to the implementation of Health-Promoting School programmes targeting bullying and violence: a systematic review

Health-Promoting School (HPS) interventions aim to reduce bullying and violence via curriculum, environmental and family/community-engagement components. Despite evidence of their effectiveness, factors influencing the implementation of such interventions are poorly understood. This systematic review aims to examine such factors by assessing qualitative process evaluations of HPS interventions aiming to reduce bullying, aggression or violence. A comprehensive systematic search of 12 databases was carried out, and 20 reports from 17 studies were included. Thematic synthesis was used to identify factors affecting implementation. Factors that enable implementation were related to programme characteristics and stakeholder buy-in, including support from leadership, teachers, students and parents. Good communication and staff climate were important. Interventions were better implemented when they framed health promotion as a core school business, were supported by a national policy, used local data to show need and effectiveness and provided high-quality, pragmatic and accessible staff training. The results of this review can serve to guide and facilitate the design and implementation of future bullying and violence prevention programmes. Since there is significant overlap in terms of the important pillars and guiding principles for all interventions guided by the HPS framework, the findings may apply to outcomes beyond bullying and violence.

Implementation Leadership in School Nutrition: A Qualitative Study

OBJECTIVE

This paper identifies implementation leadership characteristics in the school nutrition setting and places findings in the context of implementation leadership literature.

METHODS

Fourteen interviews were conducted with school district leadership/staff in an urban school district. Modified grounded theory was employed.

RESULTS

Four themes emerged: (1) understanding of technical/operational intervention details; (2) ability to proactively develop and communicate plans; (3) supervisory oversight; and (4) intervention framing. Themes were consistent with 4 of the 5 dimensions comprising the Implementation Leadership Scale: knowledgeable, proactive, perseverant, and distributed leadership. The supportive domain was not a major finding. An additional domain, how leaders message the intervention to staff, was identified.

CONCLUSIONS AND IMPLICATIONS

Implementation leadership in school nutrition appears similar, but not identical, to leader behaviors present in the Implementation Leadership Scale. School nutrition leaders might consider involving staff early in implementation planning, incorporating technical expertise, and clearly communicating the intervention purpose to support successful implementation. Future research might explore the interplay between leadership and implementation outcomes.

Process evaluation of a pre-adolescent transdisciplinary health intervention for inter-generational outcomes

Background

The CIrCLE of Life Initiative was implemented to 537 grade 6 learners and their parents, in five Government-run South African primary schools. The transdisciplinary intervention was intended to increase knowledge and skills on HIV and obesity. The study aim was to assess and report on the implementation process.

Methods

Data was collected on an adapted Proctor’s taxonomy of implementation outcomes, and to assess participants’ experiences. Qualitative and quantitative data were collected through educator logbooks, researcher observations, and learner-parent workbooks.

Results

Differentiations between the various school contexts were observed. The process evaluation revealed high learner penetration (97.2%), but lower learner and parent exposure (44.3% and 55.5%, respectively). All educators thought that the intervention was a fit for both rural and urban schools, different socio-economic groups, and people of different ethnic and cultural backgrounds. The intervention was perceived to be sustainable, and there were recommendations for adoption into the school curriculum and scale-up if found to be effective.

Conclusion

The process evaluation facilitated the assessment of the implementation outcomes, described its processes, and acknowledged fundamental characteristics that could justify variability in the intervention impact and outcomes. The value of process evaluations and their benefit to the science of implementation were demonstrated.

Enablers and barriers English secondary schools face in promoting healthy diet and physical activity behaviours

This study sought to understand the current challenges mainstream secondary schools in England face in creating a health promoting school culture for diet and physical activity behaviours. An in-depth qualitative case study of two purposely selected state-funded schools, including interviews with teachers, observations of school activities including meal breaks and a qualitative survey with parents was done. Inductive thematic analysis was used to explore emerging themes. Additional interviews with the leadership team from four further schools were used to develop and refine emerging themes. Four main themes emerged from the data: competing pressures, school environment, personnel and policy. Results demonstrate that schools recognize they have role to play in promoting healthy lifestyle behaviours to pupils; however, several significant barriers were identified such as lack of government support and regulation, school structures and organization, focus on core subjects, business-run canteens and lack of family and community engagement. Given the importance of maintaining a healthy weight throughout the life course, schools have an important role to play in creating healthy environments in which students can easily make a healthy choice. Future school promotion initiatives need to consider addressing the barriers that schools face by working with them and the communities in which they are embedded.

There has been little research done in secondary schools to understand how to promote healthy lifestyle behaviours to adolescents (secondary schools provide secondary education for students aged 11–18 years). COVID-19 has brought the importance of maintaining a healthy weight back into sharp focus and schools are an ideal setting to educate and support young people in making healthy diet and activity choices. This research sought to understand how important school staff thought creating a health-promoting culture in schools was, how they could create such a culture and what support they had or needed to do so. From interviews with school staff, observing school activities and a questionnaire to parents, we found that schools and parents believe that schools have a role to play in supporting healthy diet and physical activity behaviours although they identified many pressures that prevent making health promotion a priority; these include time and resources as well as a lack of government policy. The importance of having a head teacher with a belief in the benefits of a healthy lifestyle was recognized. The way secondary schools are structured in England makes a joined-up approach difficult and requires central planning and coordination. More support, including resources and policy commitments, are needed to support secondary schools to create a healthy school environment.

Themes in Train-the-Trainer Nutrition Education Interventions Targeting Middle School Students: A Systematic Review

Context-appropriate nutrition education interventions targeting middle school students have the potential to promote healthy dietary patters that may help prevent unnecessary weight gain at a point in childhood development when youth experience increasing agency over their food choices. The aim of this review was to identify and synthesize themes in train-the-trainer approaches, intervention content and delivery, and youth receptivity across teacher, mentor, and peer-led nutrition education interventions that targeted middle school-age youth in urban, primarily low-income settings. A systematic, electronic literature search was conducted in seven electronic databases, PubMed/Medline, CINAHL, ERIC, PsycINFO, Scopus, SPORTDiscus, and Cochrane CENTRAL, using fixed inclusion and exclusion criteria. A total of 53 papers representing 39 unique interventions were selected for data extraction and quality assessment. A framework synthesis approach was used to organize the interventions into six categories and identify themes according to whether the intervention was classroom-based or out-of-school-based and whether adults, cross-age peers or same-age peers delivered the intervention. Ten of the interventions contained multiple components such that they were included in two of the categories. The review findings indicated that trainings should be interactive, include opportunities to role-play intervention scenarios and provide follow-up support throughout intervention delivery. Interventions targeting middle school youth should include positive messaging and empower youth to make healthy choices within their specific food environment context.

School-Based Health Literacy Programs for Children (2-16 Years): An International Review

BACKGROUND

Health literacy impacts children's health and educational attainment. Therefore, determining the most appropriate pedagogical design is critical. The long-term health benefits of health literacy for each child's life course further justify this imperative. School-based health literacy programs are of interest internationally.

METHODS

We brainstormed the search terms and established inclusion/exclusion criteria for this systematic review. We searched 2 databases (CINAHL, ERIC) following PRISMA guidelines. Three authors screened and sorted the findings.

RESULTS

We identified 21 relevant studies from 629 retrieved. Few (6/21) studies were situated in the primary school setting.

CONCLUSIONS

This review found a variety of project designs, evaluation methods, and conceptual models. Descriptive analysis of the final 21 papers highlighted the importance of multicomponent design (whole-of-school and curriculum), cross-curricula integration, professional development for teachers, age of children, role of parents, and role of community. The results of this analysis may inform primary school program design in the future. Schools provide a logical setting for health literacy development. Despite the evidence that adolescence is too late, few studies have been situated in primary schools. Teachers lack confidence to teach health and need ongoing professional development. Parent, child, and community voices are essential for sustained engagement and program success.

Implementation of a school-based physical activity intervention for Brazilian adolescents: a mixed-methods evaluation

The effectiveness of physical activity interventions can be improved through examining the aspects related to their implementation. However, little such evidence has been collected, particularly in low- and middle-income countries. This study aimed to evaluate the implementation of a school-based physical activity intervention with qualitative and quantitative data from different actors (students, teachers and parents) involved in developing the program. The program was conducted in 2017 with three main components: (i) teacher training, (ii) environmental changes and (iii) educational actions. Mixed-method evaluation was performed by an independent evaluation team using a validated indicator matrix for the implementation process, including the self-reported information of students, teachers and parents, as well as interviews with teachers. In the 3 eligible schools, 350 adolescents (51% girls) answered the implementation questionnaire, as did 45 parents (84% mothers), and 47 teachers (70% female). In the qualitative analysis, 18 teachers participated. Categorical analysis found that the intervention was considered feasible by teachers. In general, teachers had a more positive perception of the implementation than did students. The lack of engagement from the school community and parents and the busy schedule of teachers were indicated to be the main difficulties. In conclusion, despite the teachers' motivation, some barriers prevented the successful implementation of the program.

What Do Secondary Schools Need to Create Healthier Canteens? The Development of an Implementation Plan

Introduction: The Netherlands Nutrition Centre developed guidelines to improve the availability and accessibility of healthier food products in Dutch canteens. This paper describes the development of an implementation plan to facilitate implementation of Guidelines for Healthier Canteens in Dutch secondary schools. Materials and Methods: In cooperation with stakeholders (i.e., school/caterer managers/employees, school canteen advisors, researchers) and based on theory, we developed an implementation plan in three steps. First, we identified factors that impede/facilitate stakeholders to create a healthier school canteen during 14 interviews. Second, 25 experts discussed and prioritized these identified factors in an expert meeting. Third, we translated these factors into tools to be included in the implementation plan, by making use of behavior change taxonomies and evidence-based implementation strategies. Results: The plan aims to support stakeholders in implementing healthier school canteens and consists of five tools: (1) tailored advice based on an online questionnaire to assess schools' and stakeholders' context and the Canteen Scan (i.e., an online tool to assess the availability and accessibility of food/drink products); (2) communication materials with information and examples; (3) online community for support by sharing experiences/questions; (4) digital newsletter as reminder/support; (5) fact sheet with students' needs/wishes to tailor the canteen. Discussion: This study illustrates how collaboration between science, policy and practice resulted in a tailored implementation plan aimed to support schools to adhere to school canteen policy. This development serves as a good example for researchers, health promotion policymakers, and practitioners how to create an implementation plan that fits the needs of stakeholders.

Headteachers' and chairs of governors' perspectives on adolescent obesity and its prevention in English secondary school settings

BACKGROUND

Secondary schools are an important setting for preventing obesity in adolescence. Headteachers and chairs of governors are identified in national guidance as crucial stakeholders for school-based preventative action. Despite this, their views remain unexplored and unrepresented.

METHODS

A sequential mixed method study was conducted. Semi-structured interviews were undertaken with a purposive sample of 22 secondary school headteachers and chairs of governors in England. Data were thematically analysed and informed the development of a descriptive cross-sectional survey, completed by 127 participants from the same population.

RESULTS

Unhealthy dietary and sedentary behaviours were viewed as a more significant problem than adolescent obesity. Obesity was perceived as complex and multi-causal, and a range of stakeholders were deemed to have responsibility for its prevention, most notably parents. Support was identified for the role of secondary schools, although this was not an explicit priority and extensive internal and external barriers exist, which hinder preventative action.

CONCLUSIONS

Whilst secondary school settings in England remain an important setting for the prevention of adolescent obesity, it is crucial for policy makers and public health professionals to recognize the factors affecting school leaders' ability and willingness to contribute to this agenda.

Identifying factors associated with overweight and obesity among intermediate school students aged 12-15 years in school settings: mixed-methodology protocol

INTRODUCTION

Childhood obesity is a public health concern globally. In Arab countries, the prevalence of overweight and obesity has increased significantly over the last three decades. The level of childhood overweight and obesity in the Kingdom of Saudi Arabia (KSA) is high and continues to increase. This study will explore factors associated with overweight and obesity among adolescents and identify barriers and enablers to the implementation of comprehensive school-based obesity prevention interventions.

METHODS AND ANALYSIS

Socioecological model will inform this mixed-methods study. The study will include three phases: (1) a scoping review of the literature; (2) the development of a student survey instrument and (3) a mixed-method study comprising a cross-sectional survey targeting students aged 12-15 years with the collection of the students' height and weight measurements; one-on-one interviews with physical education teachers and school principals; and the administration of school climate audits using the Health Promoting School framework. Reliability and validity of the survey instrument will be examined during survey development. Descriptive, inferential and thematic analysis will be employed using appropriate statistical software.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Curtin University of Human Research Ethics Committee (HR2020-0337) and from the KSA Ministry of Education (4181827686). School principals will provide permission to conduct the study in individual schools. Individual consent/assent will be obtained from students and their parents, and teachers. Study findings will be disseminated via peer-review publications, reports and conferences.

Implementation of a Dutch school-based integrated approach targeting education, health and poverty-a process evaluation

This study provides an evaluation of the implementation of a school-based integrated approach to improve academic outcomes by targeting children’s education, health, and poverty. A two-year municipal subsidy program was provided to four primary schools in a deprived urban neighborhood in Amsterdam. Schools were put in charge of the implementation and coordination of the program. The municipality and district authorities provided assistance. This study evaluated whether the program functioned as integrated approach, i.e., whether it targeted multiple domains and environments by involving various agencies and actors, and what factors facilitated or hampered this. It also yielded an overview of the initiatives implemented and the facilitators and barriers of successful implementation of initiatives. Principals’ perceptions served as the main input for this study. We thematically analyzed seven written customized plans for spending the subsidy (one to two per school), 15 transcripts of interviews with the principals (three to four per school) and the minutes of 16 meetings between principals, policy officers, and researchers. According to the principals, the schools had made great progress in the education domain and in improving the school’s pedagogical climate, but in the health and poverty domains less progress had been made. Apart from the municipality, relatively few external agencies and actors had been actively involved in the program, and progress in other environments than the school was hardly achieved. This study shows that functioning of the program as integrated approach was facilitated by connections between initiatives, and that hired, well-trusted third parties may be crucial to establish these connections.

Lay summary

This study evaluated whether a two-year municipal program to improve academic outcomes by targeting children’s education, health, and poverty, provided to primary schools in a deprived urban neighborhood, functioned as intended, and if so why, or if not, why not. The program was intended to function as integrated approach. This means that it was supposed to target the mentioned domains, the school, home, and neighborhood environment, and to involve various agencies and actors, such as school staff, policy officers, parents, children, and external organizations. The school principals could implement multiple, self-chosen, initiatives. According to the principals, on whose perceptions this evaluation study was primarily based, both teaching and the school climate improved during the program. However, improvements in children’s health and poverty levels, and outside the school environment in general, were more difficult to achieve. In addition, the program involved mainly school staff and policy officers. The program thus functioned as an integrated approach, but only to a limited extent. The functioning of the program as integrated approach was facilitated by involving hired third parties to stimulate interconnection of initiatives, i.e., initiatives serving the same goals, involving multiple agencies and actors, and/or being implemented in the same location.

A cluster randomised controlled trial of a secondary school intervention to reduce intake of sugar-sweetened beverages: Mid-intervention impact of switchURsip environmental strategies

ISSUE ADDRESSED

Secondary schools provide an opportune setting for interventions addressing excessive sugar-sweetened beverage (SSB) intake in adolescence. This trial aimed to assess the impact of school environmental strategies, delivered as part of a broader intervention, among Year 7-9 students' SSB consumption.

METHODS

Between March and July 2018, we conducted a cluster randomised controlled trial with 862 students attending six secondary schools (3 intervention and 3 control) in New South Wales. The intervention targeted SSB availability, placement, promotion and pricing, and increased availability and promotion of water. Control schools followed their usual programmes. Primary outcomes included mean daily SSB consumption (millilitres) and mean daily percentage energy from SSB (kilojoules). Sub-group analysis explored primary outcomes for gender, school year level and frequency of canteen use.

RESULTS

Of the 2265 eligible students, 1092 (50.2%) provided active parental consent and 940 (86.0%) participated in baseline data collection. No significant differences were observed between groups at follow-up for mean daily SSBs consumed (-10.17 mL, CI: -24.78; 45.12, P = 0.57) or mean daily percentage energy from SSBs (-0.20%, CI: -0.87; 0.47, P = .56). Significant effects were observed among girls in intervention compared to girls in control schools for mean daily SSB consumption (-52.02 mL, CI 99.8; 94.14, P = .03) and mean daily percentage of energy from SSBs (-0.90%, CI: -1.82; 0.02, P = .05).

CONCLUSIONS

At 3-month mid-intervention evaluation, the intervention failed to impact on mean daily consumption and mean percentage energy from SSBs, overall. However, an intervention effect was observed in girls. The limited overall effect is likely due to inadequate intervention dose related to the short duration, limiting opportunities for schools to fully implement the environmental strategies. SO WHAT?: A longer intervention duration with additional implementation support to allow adequate time to embed the strategies within the school is recommended. Implementation support strategies would ensure staff are supported throughout the process.

Can Health-Promoting Schools Contribute to Better Health Behaviors? Physical Activity, Sedentary Behavior, and Dietary Habits among Israeli Adolescents

Schools with health-promoting school (HPS) frameworks are actively committed to enhancing healthy lifestyles. This study explored the contribution of school participation in HPS on students' health behaviors, namely, physical activity (PA), sedentary behavior, and dieting. Data from the 2018/2019 Health Behavior in School-aged Children study on Israeli adolescents aged 11-17 years were used. Schools were selected from a sample of HPSs and non-HPSs. Between-group differences and predictions of health behavior were analyzed. No between-group differences were observed in mean number of days/week with at least 60 min of PA (HPS: 3.84 ± 2.19 days/week, 95% confidence interval of the mean = 3.02-3.34; non-HPS: 3.93 ± 2.17 days/week, 95% confidence interval of the mean = 3.13-3.38). Most children engaged in screen time behavior for >2 h/day (HPS: 60.83%; non-HPS: 63.91%). The odds of being on a diet were higher among more active children (odds ratio [OR] = 1.20), higher socio-economic status (OR = 1.23), and female (OR = 2.29). HPS did not predict any health behavior. These findings suggest that HPSs did not contribute to health behaviors more than non-HPSs. Therefore, health-promoting activities in HPSs need to be improved in order to justify their recognition as members of the HPS network and to fulfill their mission.

Technology clinical trials: Turning innovation into patient benefit

Health care needs to continuously evolve and innovate to maintain the health of populations. Technology has the potential to enable better patient engagement and ownership, as well as optimise therapeutic interventions and data-science approaches to facilitate improved health care decisions. Yet, to date, technological innovation has not resulted in the rate of change that could have been predicted from other sectors. This article discusses multiple reasons for this and proposes a newly tested and deployed solution: the technology clinical trial. The technology clinical trial methodology has been developed through working directly with patients, clinical and medical devicetrial experts. This approach enables researchers to use the complex environment of health care as an opportunity to transform the pace of innovation and create new care pathways. Instead of testing a single innovation, researchers can 'step back' and systematically review all areas of the patient's journey for potential optimization. Then integrate novel data science, technological advances, process updates, behavioural science, and patient engagement to co-create a streamlined multidisciplinary solution. As a result, this research has the potential for larger advances due to the emergent benefits that can arise when the individual elements work together as a whole. These potential benefits are then robustly tested, characterised and measured in the trial environment to ensure that future application of the innovative pathway is supported by the robust empirical data health care requires.

What do children, parents and staff think about a healthy lifestyles intervention delivered in primary schools? a qualitative study

OBJECTIVE

Primary schools are crucial settings for early weight management interventions but effects on children's weight are small and evidence shows that deficiencies in intervention implementation may be responsible. Very little is known about the roles of multiple stakeholders in the process of implementation. We used a multiple-stakeholder qualitative research approach to explore the implementation of an intervention developed to improve the diet and increase the levels of physical activity for children living in some of the most deprived areas of England.

DESIGN

For this qualitative study, interviews and focus groups were carried out using semi-structured topic guides. Data were analysed thematically.

SETTING

Seven primary schools (pupils aged 4 to 11) in Manchester, England.

PARTICIPANTS

We conducted 14 focus groups with children aged 5 to 10 years and interviews with 19 staff members and 17 parents.

INTERVENTION

Manchester Healthy Schools (MHS) is a multicomponent intervention, developed to improve diet and physical activity in schools with the aim of reducing and preventing childhood obesity.

RESULTS

Three themes were developed from the data: common understandings of health and health behaviours; congruence and consistency of messages; negotiations of responsibility.

CONCLUSION

All participant groups had a common conceptualisation of health as having physical and psychological components and that action could be taken in childhood to change behaviours that protect long-term health. When parents and staff felt a shared sense of responsibility for children's health and levels of congruence between home and school norms around diet and physical activity were high, parents and children were more likely to accept the policies implemented as part of MHS. Effective two-way communication between home and school is therefore vital for successful implementation of this intervention.

Effects of the KEIGAAF intervention on the BMI z-score and energy balance-related behaviors of primary school-aged children

The aim of the current study was to evaluate the one- and two-year effectiveness of the KEIGAAF intervention, a school-based mutual adaptation intervention, on the BMI z-score (primary outcome), and energy balance-related behaviors (secondary outcomes) of children aged 7-10 years.A quasi-experimental study was conducted including eight intervention schools and three control schools located in low socioeconomic neighborhoods in the Netherlands. Baseline measurements were conducted in March and April 2017 and repeated after one and 2 years. Data were collected on children's BMI z-score, sedentary behavior (SB), physical activity (PA) behavior, and nutrition behavior through the use of anthropometric measurements, accelerometers, and questionnaires, respectively. All data were supplemented with demographics, and weather conditions data was added to the PA data. Based on the comprehensiveness of implemented physical activities, intervention schools were divided into schools having a comprehensive PA approach and schools having a less comprehensive approach. Intervention effects on continuous outcomes were analyzed using multiple linear mixed models and on binary outcome measures using generalized estimating equations. Intervention and control schools were compared, as well as comprehensive PA schools, less comprehensive PA schools, and control schools. Effect sizes (Cohen's d) were calculated.In total, 523 children participated. Children were on average 8.5 years old and 54% were girls. After 2 years, intervention children's BMI z-score decreased (B = -0.05, 95% CI -0.11;0.01) significantly compared to the control group (B = 0.20, 95% CI 0.09;0.31). Additionally, the intervention prevented an age-related decline in moderate-to-vigorous PA (MVPA) (%MVPA: B = 0.95, 95% CI 0.13;1.76). Negative intervention effects were seen on sugar-sweetened beverages and water consumption at school, due to larger favorable changes in the control group compared to the intervention group. After 2 years, the comprehensive PA schools showed more favorable effects on BMI z-score, SB, and MVPA compared to the other two conditions.This study shows that the KEIGAAF intervention is effective in improving children's MVPA during school days and BMI z-score, especially in vulnerable children. Additionally, we advocate the implementation of a comprehensive approach to promote a healthy weight status, to stimulate children's PA levels, and to prevent children from spending excessive time on sedentary behaviors.Trial registrationNetherlands Trial Register, NTR6716 ( NL6528 ), Registered 27 June 2017 - retrospectively registered.

Health Promoting School Interventions in Latin America: A Systematic Review Protocol on the Dimensions of the RE-AIM Framework

Understanding the dimensions of internal and external validities (e.g., using the RE-AIM model: Reach, Effectiveness/Efficacy, Adoption, Implementation, and Maintenance) of school interventions is important to guide research and practice in this context. The aim of this systematic review protocol is to synthesize evidence on the RE-AIM dimensions in interventions based on the Health Promoting School (HPS) approach from the World Health Organization (WHO) in Latin America. Studies of interventions based on HPS-WHO that were carried out in Latin America involving the population of 5 to 18-year-olds will be eligible. Searches in nine electronic databases, a study repository, the gray literature, and the retrieved articles' reference lists will be performed, without year or publication language limits. Study selection and data extraction will be conducted by independent researchers. Data on intervention implementation will be summarized in categories of HPS-WHO actions: (1) school curriculum, (2) changes in the social and/or physical environment of schools, and (3) actions with families and the community. A previously validated tool will be used to summarize the information on the dimensions of the RE-AIM model. The strengths and limitations of the included studies will be evaluated using the Critical Appraisal Skills Program (CASP) tool, and the confidence level of evidence will be assessed according to the GRADE CERQual tool.

Involving Parents to Help Improve Children's Energy Balance-Related Behaviours Through a School-Based Intervention

The Challenge Me intervention aimed to indirectly involve parents in a school-based intervention, by challenging primary school children to perform physical activity (PA) and nutrition-related activities with their parents. The aim of this study is to gain insight in whether this was a feasible strategy to engage children and parents, especially those of vulnerable populations. An exploratory cross-sectional study design was applied. Four primary schools implemented the intervention. Data consisted of challenges completed (intervention posters) and child and family characteristics (questionnaires and anthropometric measurements). Associations between challenges performed and child and family characteristics were assessed using linear regression analysis. Of the 226 study participants, 100% performed at least one challenge, and 93% performed at least one challenge involving parents. Children who performed more PA challenges were often younger, a sports club member, lived in higher socioeconomic status neighbourhoods, of Western ethnicity and from larger families. Regarding nutrition challenges involving parents, younger children performed more challenges. There was no difference in intervention engagement regarding gender, weight status, PA preference, healthy nutrition preference, or the Family PA and Family Nutrition Climate. Challenge Me has potential in involving parents in a school-based intervention. However, certain characteristics were associated with higher involvement.

Implementing health-promoting schools to prevent obesity

Purpose

Obesity in children and adolescents is a significant public health concern. The World Health Organization Health Promoting Schools (HPS) framework promotes good nutrition and physical activity in school settings. While HPS is embraced globally, effective implementation and sustainable programmes are a continued challenge. This paper aims to report on the characteristics of current school interventions based on HPS and implementation barriers and enablers.

Design/methodology/approach

A literature search identified peer-reviewed studies of school health interventions reflective of the HPS framework focusing on obesity prevention. Studies from all countries were included, if conducted in primary and/or secondary schools; included a sufficient amount of qualitative implementation or process evaluation data to draw conclusions regarding key barriers and enablers to implementation; and were published in English.

Findings

Nine interventions (n = 9) from seven countries were included. Most were implemented in primary schools and focused on specific grade levels. Engaging parents, the home environment, teacher time constraints, fun interventions, student participation, teacher training, integration with the curriculum and stakeholder engagement all emerged as strong implementation themes. Teachers as role models, establishing community partnerships and policy support also emerged as common themes.

Originality/value

Future interventions may benefit from enhancing teacher and parent health promotion. Partnerships with initiatives focusing on environmental sustainability may simultaneously benefit human and planetary health while strengthening stakeholder engagement opportunities and consistent messaging throughout the community. More comprehensive evaluation data are needed, in particular, for long-term HPS initiatives.

Are primary/elementary school-based interventions effective in preventing/ameliorating excess weight gain? A systematic review of systematic reviews

This systematic review of systematic reviews addresses a current gap in evidence by synthesizing findings relating to weight management interventions set entirely in primary/elementary schools targeting, diet, and/or physical activity as key strategies. Eight databases were searched for systematic reviews of trials of school-based interventions targeting children aged 4 to 12 years that looked at biometric and behavioral outcomes. From the 10 selected systematic reviews, we found that interventions designed to promote physical activity or reduce sedentary behavior were most effective for weight loss. Interventions designed to improve diet and nutrition had a small effect on behavioral and cognitive outcomes, and these outcomes could be enhanced through the use of experiential learning. The most effective interventions involved a range of stakeholders in the development process and included parents and families in implementation. This systematic review of systematic reviews offers evidence-based guidance for the development and implementation of multistrategy weight-management interventions in primary/elementary schools.

The impact of the World Health Organization Health Promoting Schools framework approach on diet and physical activity behaviours of adolescents in secondary schools: a systematic review

OBJECTIVE

To examine the effectiveness of interventions using the World Health Organization Health Promoting Schools (HPSs) framework approach in increasing physical activity (PA) and improving the diet of 11-18-year-olds.

STUDY DESIGN

A systematic review guided by the National Health Services Centre for Reviews and Dissemination framework and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses.

METHODS

Nine databases and trial registries were searched from 2013 to 2018 for cluster randomised controlled trials involving adolescents' aged 11-18 years. We also included relevant studies from a 2014 Cochrane Review of HPS approach on health behaviours. Data were extracted from included studies and assessed for quality.

RESULTS

Twelve eligible studies were identified from seven countries. The studies varied in outcome measures, sample size, quality and duration of intervention and follow-up. Only four of the included studies were of high to moderate quality. We found some evidence of effectiveness for physical activity only interventions and limited evidence of effectiveness for nutrition only and combined PA and nutrition interventions.

CONCLUSIONS

There were no discernible patterns across the studies to suggest effective mechanisms for the HPS approach. The family/community component was poorly developed and superficially reported in all studies. Future research should seek to understand how best to work in partnership with secondary schools, to foster and sustain a healthy eating and physical activity culture, which aligns with their core aims. More attention should be paid to the restriction of unhealthy foods in the school environment.

Using Theory to Develop Healthy Choices in Motion, a Comprehensive, Experiential Physical Activity Curriculum

Background: Research has shown that engaging in regular physical activity supports physiologic, metabolic, and immunologic processes, as well as quality of life. However, few youth in the United States meet the U.S. Department of Health and Human Services recommendation of 60 min of moderate-to-vigorous physical activity every day. School-based programs can be an effective avenue for engaging youth in physical activity, particularly when the design of the health education is based on theory, research, and practice. The purpose of this study was to design, implement, and evaluate a theory-driven physical activity curriculum for the Shaping Healthy Choices Program (SHCP) using a systematic approach.

Methods: The experiential, inquiry-based physical activity curriculum, Healthy Choices in Motion (HCIM), was developed with an optional technology enhancement using Backward Design. A questionnaire to assess the curriculum's effect on physical activity knowledge was developed and assessed for content validity, internal consistency (α = 0.84), and test-retest reliability (r = 0.73). The curriculum was piloted in two phases among upper elementary-aged youth: to ensure the learning goals were met (Pilot I) and to determine the curriculum's impact on physical activity knowledge, behavior, and self-efficacy (Pilot II). Pilot II was implemented among eight 4th and 5th-grade classrooms participating in the UC CalFresh Nutrition Education Program: (1) Comparison (no intervention) (n = 25); (2) SHCP only (n = 22); (3) SHCP + HCIM (n = 42); (4) SHCP + HCIM with technology enhancement (n = 47). Analyses included unadjusted ANOVA and Bonferroni for multiple comparisons and paired t-test (p < 0.05).

Results: Through the use of a methodical design approach, a comprehensive physical activity curriculum, called HCIM, was developed. Youth participating in HCIM improved physical activity knowledge compared to youth receiving no intervention (+2.8 points, p = 0.009) and youth only in the SHCP (+3.0 points, p = 0.007). Youth participating in HCIM with technology enhancement demonstrated improvements compared to youth only in the SHCP (+2.3 points, p = 0.05).

Conclusion: Improvements in physical activity knowledge in youth participating in HCIM may contribute to improvements in physical activity and should be further explored in conjunction with behavioral measurements.

Implementation of KEIGAAF in Primary Schools: A Mutual Adaptation Physical Activity and Nutrition Intervention

School health promotion is advocated. Implementation studies on school health promotion are less often conducted as effectiveness studies and are mainly conducted conventionally by assessing fidelity of "one size fits all" interventions. However, interventions that allow for local adaptation are more appropriate and require a different evaluation approach. We evaluated a mutual adaptation physical activity and nutrition intervention implemented in eight primary schools located in low socioeconomic neighborhoods in the Netherlands, namely the KEIGAAF intervention. A qualitative, multiple-case study design was used to evaluate implementation and contextual factors affecting implementation. We used several qualitative data collection tools and applied inductive content analysis for coding the transcribed data. Codes were linked to the domains of the Consolidated Framework for Implementation Research. NVivo was used to support data analysis. The implementation process varied greatly across schools. This was due to the high level of bottom-up design of the intervention and differing contextual factors influencing implementation, such as differing starting situations. The mutual adaptation between top-down and bottom-up influences was a key element of the intervention. Feedback loops and the health promotion advisors played a crucial role by navigating between top-down and bottom-up. Implementing a mutual adaptation intervention is time-consuming but feasible.

Food and nutrition education opportunities within Australian primary schools

Schools are regarded as a key setting for obesity prevention, providing an opportunity to reach a large number of children, frequently and over a prolonged period, through formal and informal opportunities to learn about health behaviours. However, the low value placed on health versus academic achievement is a barrier to effective implementation of food and nutrition (F&N) education. This study used a qualitative exploratory approach to explore the views of teachers and key health and education sector stakeholders regarding opportunities for F&N education within the Australian primary school setting. To the best of our knowledge, this is the first study to explore this topic from the perspectives of state-level coordination and development through to local-level implementation and support within the Australian primary school context. Only 2.6% of the Victorian Curriculum related to F&N education, taught through two (of seven) learning outcomes: Health and Physical Education, and Technologies. While stakeholders considered child health a priority, and schools an ideal setting for F&N education, barriers included a lack of strategic policy alignment, limited leadership and coordination, a ‘crowded curriculum’ and poor availability of shelf-ready resources with explicit curriculum links. A cross-curriculum approach was considered essential for F&N education to become embedded as a core component of the curriculum.

The feasibility and acceptability of a primary school-based programme targeting diet and physical activity: the PhunkyFoods Programme

Background

This study aims to evaluate the feasibility and acceptability of the PhunkyFoods Programme, a primary school-based intervention to promote healthy nutrition and physical activity knowledge and behaviours to assess outcomes to inform a phase 3 trial.

Methods

The cluster randomised feasibility trial recruited eight primary schools from the North of England. Elibility criteria included all primary schools in one town, excluding independent and special schools and schools that comprised of only key stage 2 pupils (years 3–6). Eight schools agreed to participate. Randomisation to intervention or control arms was in a 1:1 ratio. Intervention schools received PhunkyFoods over 17 months. Control schools continued with usual curriculum. Assessors were blinded to group assignment. Measures comprised of a Healthy Lifestyle Knowledge Questionnaire and Synchronised Nutrition and Activity Program to assess diet and physical activity, height, weight, and psychological wellbeing. Feasibility outcomes were recruitment, attrition rates, interviews with teaching staff, focus groups with pupils to explore the acceptability of outcome measures, implementation, intervention content, and programme fidelity.

Results

Three hundred fifty-eight pupils, aged 6–9 years from eight schools were recruited at baseline (control n = 170, intervention n = 188); 337 (94.1%) at 6 months (control n = 163, intervention n = 181); and 331 (92.5%) at 18 months (control n = 152, intervention n = 179), and 6 pupils opted out. Trends in increased knowledge of healthy lifestyle behaviours, healthier eating, and liking of fruit and vegetables were reported in the intervention compared to the control group. Year 4 intervention pupils had significantly higher healthy balanced diet knowledge scores compared to control pupils, mean difference 5.1 (95% CI 0.1 to 10.1, p=0.05). At 18 months, the mean percentage of vegetables liked was higher (intervention 53.9% vs. 43.0% control). Similarly, percentage of fruits liked was also higher (intervention 76.9% vs. 67.2% control). Qualitative data showed that delivery of the intervention was feasible and acceptable to teachers and pupils. Lessons were learned to inform the phase 3 trial around the dietary assessment measure and timing of recruitment.

Conclusions

Whilst the study was not powered to detect a definitive effect, results suggest a potential to increase knowledge of healthy lifestyle behaviours and dietary behaviours, suggesting that with minor changes, a phase 3 trial is likely to be deliverable.

Trial registration

ISRCTN, ISRCTN15641330. Registered 8 May 2015—retrospectively registered, 10.1186/ISRCTN15641330

Implementation of Guidelines for Healthier Canteens in Dutch Secondary Schools: A Process Evaluation

The Netherlands Nutrition Centre has developed ‘Guidelines for Healthier Canteens’. To facilitate their implementation, implementation tools were developed: stakeholders’ questionnaires, the ‘Canteen Scan’ (an online tool to assess product availability/accessibility), a tailored advisory meeting/report, communication materials, establishment of an online community, newsletters, and a fact sheet with students’ wishes/needs. In this quasi-experimental study, we investigated the effect of these tools in secondary schools on (a) factors perceived by stakeholders as affecting implementation; (b) the quality of implementation. For six months, ten intervention schools implemented the guidelines, supported by the developed implementation tools. Ten control schools received the guidelines without support. School managers, caterers, and canteen employees (n = 33) reported on individual and environmental factors affecting implementation. Implementation quality was determined by dose delivered, dose received, and satisfaction. Stakeholders (n = 24) in intervention schools scored higher on the determinants’ knowledge and motivation and lower on need for support (p < 0.05). Dose received (received and read) and satisfaction was highest for the advisory meeting/report (67.9%, 64.3%, 4.17), communication materials (60.7%, 50.0%, 3.98), and fact sheet (80%, 60%, 4.31). Qualitative analyses confirmed these quantitative results. In conclusion, a combination of implementation tools that includes students’ wishes, tailored information/feedback, reminders and examples of healthier products/accessibility supports stakeholders in creating a healthier school canteen.

Trends in overweight and obesity by socioeconomic status in Year 6 school children, Australian Capital Territory, 2006-2018

Background

Due to the high prevalence and adverse consequences, overweight and obesity in children continues to be a major public health concern worldwide. Socioeconomic background and health-related behaviours (such as diet, physical activity and sedentary behaviors) are important factors associated with weight status in children. Using a series of height and weight assessments from the Australian Capital Territory Physical Activity and Nutrition Survey (ACTPANS), trends in prevalence of overweight and obesity by socioeconomic status were examined in ACT Year 6 school children between 2006 and 2018.

Methods

The ACTPANS has been conducted every 3 years since 2006. A total of 6729 children were surveyed. Complete data on height and weight were available for 6384 (94.9%) participants. Trends in the prevalence of overweight and obesity and associations between weight status and risk factors (such as socioeconomic status, physical activity, screen time and consumption of sugar-sweetened soft drinks (SSD)) were examined using logistic regression.

Results

The prevalence of overweight and obesity remained stable in girls (from 22.5% in 2006 to 21.6% in 2018) but declined in boys (from 27.8 to 17.9%). During the same period, levels of physical activity increased slightly, while screen time and the consumption of fast food and SSD decreased. Socioeconomic gradient, based on the school-level Index of Community Socio-Educational Advantage (ICSEA), was highly associated with prevalence of overweight and obesity. Since 2006, the estimated prevalence of overweight and obesity has remained high in the lowest SES groups, but a concurrent downward trend was observed in the highest SES group, leading to increasing disparity between SES groups. Children in the lowest ICSEA quintile were more likely to be overweight or obese compared to those in the moderate and highest ICSEA quintiles. Children in lower ICSEA quintiles also reported lower levels of physical activity, higher levels of screen time, and higher levels of fast food and SSD consumption compared to those in higher ICSEA quintiles.

Conclusions

While recent trends in overweight and obesity in ACT children are encouraging, the prevalence remains unacceptably high, especially in those from low socioeconomic backgrounds. Additional prevention efforts are required to address the socioeconomic disparity.

School-based obesity prevention for busy low-income families-Organisational and personal barriers and facilitators to implementation

BACKGROUND

Little research has targeted multiple-level barriers and facilitators in school-based parental support programmes. This qualitative study aims to describe barriers and facilitators, at organisational and personal levels, that teachers and parents in disadvantaged settings in Sweden perceived as influencing the implementation of the Healthy School Start II (HSS II) intervention.

METHODS

Data collection, analysis and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups and interviews were conducted with 14 parents and ten teachers within the HSS II trial. Data were analysed using qualitative content analysis in a deductive step using the three CFIR domains-inner and outer setting, and personal characteristics-followed by an inductive analysis.

RESULTS

The theme 'being on the same page-getting burdened teachers and parents to work on common ground' was found. Among teachers, barriers and facilitators were related to the structure of the schoolwork and curriculum, involvement from other staff and school management, the practical school workday, perception of high family needs but low parental interest, insufficient resources in the families, and teacher's personal knowledge, interests, and opinions about health and food. For parents, barriers and facilitators were related to the perceived family needs and resources, parents' health knowledge, consensus about healthy behaviours and ability to cooperate, and school involvement in health issues and the intervention.

CONCLUSION

Interventions should facilitate parents' and teachers' work on common ground, with activities suitable for a stressful and burdensome workday and everyday life. This could be achieved by integrating evidence-based practices within school routines, and including activities that are practicable despite parents' stressful lives, and that increase parental consensus about promoting health. Strategies to increase involvement of parents in families with high needs are necessary. Also, this study suggests an expansion of the CFIR to capture the interface between different micro-level organisations, and account for several delivering/receiving organisations.

Effective implementation of primary school-based healthy lifestyle programmes: a qualitative study of views of school staff

Background

Primary schools are valuable settings to implement healthy lifestyle (healthy eating and physical activity) interventions, aimed at targeting childhood obesity. This study explored school staff perceptions of factors that hinder and enable successful implementation and sustainability of healthy lifestyle interventions in primary schools. Qualitative data was pooled and analysed from two evaluations carried out in primary schools in North England: a feasibility study of a nutrition and physical activity educational programme (PhunkyFoods Feasibility Study), and an evaluation of a healthy eating programme (The Food Dudes Evaluation).

Methods

Sixty-five qualitative semi-structured interviews were conducted with head teachers, teachers, catering managers, designated school-based programme coordinators and programme staff supporting schools with programme delivery, at 14 schools involved in both evaluations. Thematic analysis was undertaken and emergent themes categorised using a framework for successful implementation by Durlak and Dupre (2008).

Results

Overall, all schools were delivering a range of healthy lifestyle programmes, often with overlapping content. Perceived challenges to implementation of individual programmes included: limited time, timing of implementation, limited training and support, insufficient resources, capacity and facilities, staff perceptions of intervention and perceived skill-proficiency (for cooking and physical activities). Short-term funding, lack of external and internal support were perceived to hinder sustainability. Staff recommendations for successful implementation of future programmes included: extended training and planning time, sufficient capacity, external support for delivery, good resources (interactive, practical and adaptable), and facilities for cooking, healthy eating, gardening and physical activities. Head teachers need to prioritise delivery of a few key healthy lifestyle programmes, in an overcrowded curriculum. Schools need to employ strategies to engage participation of staff, pupils and parents long term.

Conclusions

Effective implementation of school-based healthy lifestyle programmes was thought to be aided by flexible and adaptable programmes, enabling good contextual fit, well-resourced programmes and effective leadership at multiple levels, pupil (pupils support delivery) and parent involvement. To facilitate sustainability, it was perceived that programmes need to be integrated within the curriculum and school policies long term, with sustained support from head teachers and staff. These findings are relevant to programme developers, policy makers and those involved in delivering interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7550-2) contains supplementary material, which is available to authorized users.

Development and Evaluation of the Implementation of Guidelines for Healthier Canteens in Dutch Secondary Schools: Study Protocol of a Quasi-Experimental Trial

Introduction: To encourage healthier food/drink choices, the “Guidelines for Healthier Canteens” were developed by the Netherlands Nutrition Centre. This paper describes (1) how we developed a plan to support implementation of the “Guidelines for Healthier Canteens” in Dutch secondary schools, and (2) how we will evaluate this plan on process and effect level.

Materials and Methods: The implementation plan (consisting of several tools) was developed in cooperation with stakeholders. Barriers/facilitators to implement the guidelines were identified by 14 interviews and prioritized during one expert meeting. Thereafter, these barriers were translated into implementation tools using behavioral change methods and implementation strategies. The implementation plan consists of the tools: tailored advice provided via an advisory meeting and report, based on a questionnaire about the stakeholders'/school's context and the “Canteen Scan,” an online tool to assess the product availability and accessibility; communication materials; an online community; newsletters; a factsheet with students' wishes/needs. This implementation plan will be evaluated on process and effect in a 6-month quasi-experimental controlled design with 10 intervention and 10 matched control schools. Process outcomes will be measured: (1) factors affecting implementation and (2) the quality of implementation, both collected via a questionnaire among involved stakeholders. Effect outcomes will be collected pre/post-intervention with: (1) self-reported purchase behavior among around 100 students per school; (2) the “health level” of the school canteen. Linear and linear/logistic two-level regression analyses will be performed.

Discussion: The implementation tools are developed by combining a theory and practice-based approach, with input from different stakeholders. If these tools are evaluated positive, it will support schools/stakeholders to create a healthier school canteen.

Trial Registration: Dutch Trial register no.: NTR5922, date of registration June 20, 2016; METC no.: 2015.331; EMGO+ project number: WC2015-008.

Translation of school-learned health behaviours into the home: student insights through photovoice

OBJECTIVE

Sedentary behaviours, physical inactivity, and poor diets in Canadian children are a major public health problem. Comprehensive school health (CSH) recognizes the importance of school and home collaboration; however, it is unknown how health behaviours promoted in school are adopted at home. The purpose of this research was to explore student perceptions of the translation of an intervention taking a CSH approach in Alberta, Canada, into the home environment.

METHODS

The guiding method was focused ethnography, using photovoice as the data generation strategy. Grades 5 and 6 students were purposively sampled (n = 25), and asked to take photos of what CSH looks like in their home environment. Subsequent one-on-one interviews were conducted as part of the photovoice process to gain a deeper understanding of student perceptions.

RESULTS

Two main themes emerged: students embraced the CSH philosophy, and students are driving change to create a healthy home culture. The underlying concept of leadership and independence was necessary for students to impact their health and the health of family members. Results demonstrated that students are catalyzing positive changes in the home environment by supporting changes in the home food environment, trying new things, facilitating improvements to healthy eating and active living, and monitoring unhealthy behaviours.

CONCLUSION

This study illustrates students' abilities to positively impact the home environment as a result of their involvement in CSH. Student leadership and independence should be promoted and emphasized in CSH to facilitate transition of health behaviours into the home environment.