Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

Gender differences in the mental symptom network of high school students in Shanghai, China: a network analysis

BACKGROUND

Adolescence is a critical period for the onset of mental health issues. In China, high school students face significant academic and social pressures, leading to high rates of mental health challenges. Gender differences in the manifestation of these symptoms have been observed, with boys and girls exhibiting distinct psychological profiles.

OBJECTIVE

This study aims to explore the structure of psychological symptoms among Chinese high school students using network analysis, focusing on identifying core symptoms and gender differences in symptom networks. The key objectives are to: 1) identify the central psychological symptoms for boys and girls, and 2) uncover the interactions between symptoms to inform targeted interventions.

METHODS

A cluster sampling method was used to recruit 3,769 high school students (2,206 males and 1,563 females) in Shanghai. The Middle School Students Mental Health Scale (MSSMHS) was administered, and network analysis was conducted using the R packages bootnet and qgraph to assess symptom network edges, centrality, and network strength. Comparisons between male and female networks were made.

RESULTS

Network analysis showed tightly connected symptom networks for both genders, with 43 non-zero edges for boys (sparsity 0.04) and 39 for girls (sparsity 0.13). Depression was the core symptom for boys (centrality 1.20), while anxiety was central for girls (centrality 1.46). Boys showed a stronger link between interpersonal sensitivity and depression (edge value 0.20), while girls exhibited a stronger connection between anxiety and obsessive-compulsive symptoms (edge value 0.16). Network comparison tests revealed no significant differences in overall network strength between boys (4.625) and girls (4.660), with P-values greater than 0.05 across all comparisons.

CONCLUSION

This study highlights significant gender differences in the psychological symptom networks of Chinese high school students. Depression and anxiety emerged as core symptoms for boys and girls, respectively. These findings provide a foundation for developing gender-sensitive mental health interventions, emphasizing the need for tailored approaches based on gender-specific symptom profiles.

Schools' readiness for child sexual abuse prevention education: Preliminary scale development using a Delphi method

BACKGROUND

This study employed a Delphi method with a panel of experts to collaboratively design a new instrument to assess schools' readiness for school-based child sexual abuse prevention education.

METHODS

An initial item pool was generated based on a review of existing empirical research and theoretical models. We invited researchers and stakeholders in the field of child sexual abuse prevention as experts to participate in a two-round online Delphi study in which they rated item importance and clarity, contributed their views on superfluous and/or missing items, gave rephrasing suggestions, and re-appraised revised items. Following the Delphi study, the instrument was pilot tested with a convenience sample of school staff.

RESULTS

The initial item pool comprised 81 items in five construct sub-scales congruent with Wiener's Organizational Readiness for Change theory: contextual factors, informational assessment, change valence, change commitment, and change efficacy. In the Delphi study, 24 experts participated in round 1, and 13 participated in round 2. Based on Delphi study responses, the instrument was reduced to 56 items in the five construct subscales: contextual factors (28 items), informational assessment (13 items), change valence (6 items), change commitment (3 items), and change efficacy (6 items). The Schools' Readiness for Child Sexual Abuse Prevention Education (SR-CSAPE) was successfully pilot tested with school staff (n = 19) and minor changes to demographic items were incorporated.

CONCLUSIONS

Informed by experts, the Schools' Readiness for Child Sexual Abuse Prevention Education (SR-CSAPE) is a newly-developed 56-item scale that identifies key organizational dimensions to schools' preparedness for CSA prevention education. Psychometric properties of the scale must be determined in future research.

Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review

Background

Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems.

Aim

To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines.

Data sources

Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022.

Results

Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models.

Conclusions

Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations.

Future work

Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues.

Limitations

This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care.

Study registration

This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

The Secret Sauce? Taking the Mystery Out of Scaling-Up School-Based Physical Activity Interventions

Over the last 4 decades, physical activity researchers have invested heavily in determining "what works" to promote healthy behaviors in schools. Single and multicomponent school-based interventions that target physical education, active transportation, and/or classroom activity breaks effectively increased physical activity among children and youth. Yet, few of these interventions are ever scaled-up and implemented under real-world conditions and in diverse populations. To achieve population-level health benefits, there is a need to design school-based health-promoting interventions for scalability and to consider key aspects of the scale-up process. In this opinion piece, we aim to identify challenges and advance knowledge and action toward scaling-up school-based physical activity interventions. We highlight the key roles of planning for scale-up at the outset, scale-up pathways, trust among partners and program support, program adaptation, evaluation of scale-up, and barriers and facilitators to scaling-up. We draw upon our experience scaling-up effective school-based interventions and provide a solid foundation from which others can work toward bridging the implementation-to-scale-up gap.

Perspectives of primary school teachers on the capacity of schools to support post-pandemic health needs emerging among school-age children

BACKGROUND

This study aimed to explore the impact of the COVID-19 pandemic on capacity building for health promotion in primary schools from the perspectives of primary school teachers.

METHODS

A cross-sectional observational study was conducted via an anonymous online survey between February and May 2022. Three-quarters (n2460) of all schools in the Republic of Ireland were invited to participate. Demographics such as gender, teaching experience, school type and delivering equality of opportunity in schools (DEIS) designation were collected. Perceived capacity for health promotion was measured on a 10-point Likert scale. Facilitators and barriers related to health promotion and aspects of child health prioritised for health promotion in the 2 years after restrictions eased were explored via closed- and open-ended questions.

RESULTS

Of the 595 responses, 493 were eligible for analysis. Participants were based in schools in every county in the Republic of Ireland, with most (85.4%, n421) being female. Almost a third (30.5%, n150) were 11-20 years post-qualification, and a quarter (25.2%, n124) had over 30 years' teaching experience. Mean capacity for school-based health promotion pre-pandemic was moderate, at 6.6 ± 2.2 on a 10-point scale. Mean capacity in spring 2022 decreased significantly (p < 0.001) to 4.1 ± 2.4, indicating poor capacity. Capacity ratings did not significantly differ by school type (p = 0.31), socioeconomic designation (p = 0.27) or years post-qualification (p = 0.08). Capacity decrements were most frequently (49.7%, n245) attributed to organisational factors, while individual and community-level factors were cited by 27.6% (n136) and 21.5% (n106) of respondents, respectively. Healthy eating significantly (p < 0.001) decreased as a priority for health promotion between pre-pandemic times (76.3%, n376) and spring 2022 (23.1%, n114). Mental health significantly (p < 0.01) increased as a priority, being listed by 38.1% (n188) as a priority pre-pandemic and doubling to 72.6% (n358) in spring 2022.

CONCLUSIONS

Fostering a holistic approach to health promotion in schools remains a challenge. Further efforts are needed to support schools to implement sustainable and balanced systems of health promotion.

Mechanisms of school-based peer education interventions to improve young people's health literacy or health behaviours: A realist-informed systematic review

INTRODUCTION

Peer education interventions are widely used in secondary schools with an aim to improve students' health literacy and/or health behaviours. Although peer education is a popular intervention technique with some evidence of effectiveness, we know relatively little about the key components that lead to health improvements among young people, or components that may be less helpful. This review aims to identify the main mechanisms involved in school-based peer education health interventions for 11-18-year-olds.

METHODS

Five electronic databases were searched for eligible studies during October 2020, an updated search was then conducted in January 2023 to incorporate any new studies published between November 2020 and January 2023. To be included in the review, studies must have evaluated a school-based peer education intervention designed to address aspects of the health of students aged 11-18 years old and contain data relevant to mechanisms of effect of these interventions. No restrictions were placed on publication date, or country but only manuscripts available in English language were included.

RESULTS

Forty papers were identified for inclusion with a total of 116 references to intervention mechanisms which were subsequently grouped thematically into 10 key mechanisms. The four most common mechanisms discussed were: 1) Peerness; similar, relatable and credible 2) A balance between autonomy and support, 3) School values and broader change in school culture; and 4) Informal, innovative and personalised delivery methods. Mechanisms were identified in quantitative, qualitative and mixed methods intervention evaluations.

DISCUSSION

This study highlights a number of key mechanisms that can be used to inform development of future school-based peer education health interventions to maximise effectiveness. Future studies should aim to create theories of change or logic models, and then test the key mechanisms, rather than relying on untested theoretical assumptions. Future work should also examine whether particular mechanisms may lead to harm, and also whether certain mechanisms are more or less important to address different health issues, or whether a set of generic mechanisms always need to be activated for success.

A realist evaluation of a multi-component program with disengaged students

Periods spent in the absence of education, employment, or training (NEET) are associated with adverse psychological wellbeing, social marginalisation, and premature mortality. Implementing effective programs to re-engage young people who are classified, or are at risk of becoming NEET, is of importance to these individuals, family, and society. We conducted a realist evaluation to understand how, and under which circumstances a multi-component program may impact the engagement, behavioural, and psychosocial outcomes of disengaged students at risk of becoming NEET. During the early project phase, a narrative review of the literature and key stakeholder discussions were conducted to develop our initial program theories regarding how the program was expected to achieve its outcomes. Participant observations, video footage, and forty-two interviews were then conducted with teachers and students to form context-mechanism-outcome configurations and to refine these theories. Overall, refined program theories relating to positions of authority, the power of collective experience, exploration of possible life directions, constructivist pedagogies and active learning, and the endorsement of an ethic of caring and strengths-based orientation were developed. Collectively, our findings provide a detailed understanding of the architecture of programs that may benefit disengaged students and help inform the design of future programs aimed at reducing disaffection.

Friendly Visiting Programs for Older People Experiencing Social Isolation: A Realist Review of what Works, for whom, and under what Conditions

Many social interventions have been developed with the hopes of reducing and preventing social isolation among older people (e.g., recreation, arts-based programs and social prescription). Friendly visiting programs, also known as befriending schemes, have been a mainstay in this area for decades and are largely thought to be effective at reconnecting older people (≥ 60 years of age) experiencing isolation. Research and evaluations have yet to determine, however, how and why these programs may be most successful, and under what conditions. This article presents the findings of a realist synthesis aimed at identifying the critical mechanisms and contextual factors that lead to successful outcomes in friendly visiting programs. Seven studies are synthesized to inform a friendly visiting program theory accounting for key mechanisms (e.g., provision of informal support) and underlying contexts (e.g., training of volunteers) that can be used to inform future programs. Recommendations for future research are also presented.

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review

BACKGROUND

Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB.

METHODS

A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust.

CONCLUSION

Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Facilitators and Barriers to the Implementation of a School-Based Intervention for Anxiety

School-based cognitive behavioural interventions for anxiety are found to be effective, but there is a lack of research on their implementation in real world settings. The current study aims to explore the facilitators and barriers to the implementation of a school-based intervention for anxiety through a qualitative process evaluation. Evaluation of the implementation of Let's Introduce Anxiety Management (LIAM), a six-session school-based cognitive behavioural intervention, was conducted. LIAM was implemented by non-mental health professionals trained and coached on the model. Semi-structured interviews with stakeholders (N = 15) were analysed with grounded theory and framework analysis. Forty-one practitioners were trained and coached on LIAM, with thirty-five children and young people receiving the intervention. Facilitators (e.g. systemic collaboration, self-efficacy and an enabling context) and barriers (e.g. the exclusivity of the intervention and a lack of systemic understanding) to implementation emerged as themes. Implementing school-based interventions is complex and requires the involvement of multiple stakeholders.

BREATHLEssness in INDIA (BREATHE-INDIA)-Study protocol for the co-design of a community breathlessness intervention in India using realist methods and intervention mapping

BACKGROUND

Breathlessness that persists despite treatment of causal disease(s) is disabling, associated with high therapy-related costs and poor socioeconomic outcomes. Low resource countries bear a disproportionate burden of respiratory problems, often characterised by disabling breathlessness. Low-cost self-management breathlessness-targeted interventions are effective and deliverable in community settings but have been developed in high-income countries. We aim to understand how breathlessness self-management works in 'real life' populations and cultural contexts, to develop programme theory and co-design a prototype intervention to improve persistent breathlessness management in India.

METHODS AND ANALYSIS

Using a Realist approach, Intervention Mapping and the Medical Research Council Complex Intervention Framework we will undertake two phases of work supported by our Expert Group (of respiratory, primary, palliative care physicians) and key stakeholder groups (opinion leader clinicians, community health workers and people with lived experiences of breathlessness). 1) Realist review and evaluation to identify and refine evidence and theory for breathlessness self-management, producing intervention and implementation programme theory. We will identify literature through our Expert Group, scoping searches and systematic searches (Medline, Ebscohost, CINAHL, Scopus, Psychinfo). We will map intervention components to 'what works, for whom, and where.' 2) Intervention development using Intervention Mapping to map intervention and implementation programme theory to intervention components, develop materials to support intervention delivery, and co-design a prototype educational intervention ready for early acceptability and delivery-feasibility testing and evaluation planning in India. Use of stakeholder groups is to allow people with experience of breathlessness and/or its management to contribute their views on content developed by our team based upon review of secondary data sources. Experts and Stakeholders are therefore not research subjects but are included as extended members of the study team and will not follow informed consent procedures. Experts and stakeholders will be acknowledge in outputs arising from our project if they wish to be. Our review conduct will be consistent with RAMESES quality standards.

DISCUSSION

At the conclusion of our study, we will have co-designed a breathlessness intervention for use in the community setting in India ready for further evaluation of: effectiveness, socioeconomic outcomes, acceptability and transferability to other low resource settings.

Reflecting on insight and insights into reflection: a systematic review of insight and reflection in post graduate medical education

BACKGROUND

Clinicians recognize insight as important for safe independent medical practice. Clinical education literature focuses on self-reflection. The aim of this review is to describe how clinical educators conceptualize reflection and ask is it analogous to how clinicians conceptualize insight?

METHODS

Using PRISMA guidelines, a systematic review of the literature around insight and reflection in postgraduate medical education was undertaken. A thematic analysis of the concepts of insight and reflection was performed.

RESULTS

A total of 75 reports were included in the analysis. The literature focussed predominantly on reflection with little discussion of insight. Three main themes were generated: episodic reflection; cyclic reflection; reflection as a state. Reflection as a state seemed to be the professional quality most often aspired to but was less well defined in terms of educational interventions. When more than one model was described, it was often with a reflective state being the ideal that episodic or cyclic reflection may approximate. It is not clear that it is possible to progress up the hierarchy.

CONCLUSION

We present a novel description of a hierarchy from discrete episodes of reflection, to cyclic processes that involve reflection, through to a state in which the practitioner is reflective. There is no unified understanding of how an individual ascends this hierarchy, or a cohesive description of what insight is for an independent medical practitioner. This review highlights the need for research into how practicing clinicians conceptualize and characterize insight in their training and practice.

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review

BACKGROUND

Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom.

METHODS

This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics.

CONCLUSIONS

Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Enhancing Student Wellbeing Through Social Prescribing: A Rapid Realist Review

Objectives: A Rapid Realist Review of social prescribing in Higher Education (HE) was undertaken to determine what works, for whom, how, why, and within what circumstances. The review resulted in the development of a Realist Programme Theory articulating the way in which social prescribing can be implemented within the HE environment. Methods: Searches of 12 electronic databases were supplemented by citation chaining and grey literature surfaced by the Project Advisory Group. The RAMESES Quality Standards for Realist Review were followed, and the retrieved articles were systematically screened and iteratively analysed to develop Context-Mechanism-Outcome Configurations (CMOCs) and an overarching Realist Programme Theory. Results: A total of 57 documents were included. The overarching programme theory was developed from the analysis of these documents and comprised of a social prescribing pathway with the following components: (1) An Accessible Gateway, (2) A Skilled Peer, (3) Trusted-Safe-Credible Resources, and (4) A Healthy Setting. Conclusion: A Realist Programme Theory was developed-this model and associated principles will provide a theoretical basis for the implementation of social prescribing pathways within higher education. Whilst the direct project outputs are of particular significance to the UK HE audience, the underpinning principles can support practice within the global arena.

A qualitative exploration of stakeholder perspectives on the implementation of a whole school approach to mental health and emotional well-being in Wales

Early intervention to support mental health and well-being of school-aged children may be of significant benefit in preventing escalation of mental health problems in later life. While there are limitations to current understanding of the best ways for schools to support mental well-being, a whole school approach (WSA), involving all those who are part of the school system in creating and sustaining a supportive environment where health is prioritized, may be effective. This research explored stakeholder views of this approach, as part of a contract commissioned by the Welsh Government to conduct an evaluability assessment of a WSA. Semistructured focus groups and interviews were completed with stakeholders from the health and education sectors, as well as parents, to explore how a WSA may operate in a Welsh context and barriers and facilitators to potential implementation and outcomes. Findings suggest that existing pressures on schools may impact implementation of a WSA, with school staff already time poor and many staff experiencing their own mental well-being challenges. Implementation may be supported by clear guidance at local and national levels, funding for staff time and training and stakeholder involvement at all stages. Long-term monitoring and evaluation are also needed to understand system changes.

Mind the gap: Danish school heads' ability to implement a national physical activity school requirement

In 2014, the Danish government introduced a wide-ranging reform of primary and lower secondary education that applied to all public schools. A distinctive feature was that it became mandatory for schools to provide an average of 45 min of daily physical activity (PA). The capacity for change of local school heads and the schools overall are considered key to fulfilling such a policy-driven requirement. The aim of this study is therefore to explore local school heads' ability to implement the stated requirement of 45 min of daily PA within their local organizational capacity for change. Eleven semi-structured interviews were conducted across 11 schools. Respondents were school staff with management responsibilities (leading teachers with school management responsibilities, deputy heads and school heads). Results indicate that local school heads are central agents in converting the Danish school requirement of 45 min of daily PA into local action. This includes their ability to advance broad aims into concrete goals, secure supportive structures and organize the implementation strategy. Heads also need to support the staff in building sufficient knowledge capacity on how to arrange and incorporate PA into their daily practice, support the widespread dissemination of this knowledge across the school and reserve work hours for such activities. Assigning local PA ambassadors was particularly highlighted as important implementation support, as they can help build and disseminate knowledge while also broadcasting the school head's strategy and focus on integrating and upholding students' PA levels.

Start small and let it build; a mixed-method evaluation of a school-based physical activity program, Kilometre Club

BACKGROUND

Despite the benefits of physical activity, there is minimal research focusing on factors that influence real-world school-based physical activity programs. Kilometre (KM) Club is an Australian grassroots program which aims to increase physical activity in students through the completion of an outside walk or run at school. This small-scale pilot evaluation aimed to examine families, teachers and principals' perceptions of the benefits, enablers and barriers of KM Club. It also aimed to examine the effects of KM Club on student's physical activity levels during the school day.

METHODS

Four regional New South Wales (NSW) primary schools participated in this study. 26 families, four teachers, and two principals from School A, C, B and D completed semi-structured interviews to understand their perceptions of KM Club. 21 students completed emotional state-scales to understand their emotions when participating in KM Club. 141 students from Schools B, C and D participated in step-count measures using accelerometers.

RESULTS

Families, teachers and principals reported a range of benefits such as improved social connectedness, wellbeing, home and classroom behaviours, participation in sport and fitness levels. Enablers consisted of champion engagement, incentives, versatile facilities and integration with other school activities. Identified barriers included the weather and environment, program timing and health issues. Most students reported that participating in KM Club made them feel proud, confident and fantastic. School B reported a significant increase in students' daily step counts on KM Club days compared to non-KM Club days (+ 15%; p = 0.001), while School C reported no significant changes (-5%; p = 0.26). School D reported a significant increase in the number of daily steps taken by KM Club participants compared with non-KM club participants (+ 10%; p = 0.024).

CONCLUSION

There is no one-size-fits-all approach to implementing school-based physical activity initiatives. However, it appears that flexible and adaptable factors are important to the successful implementation of school-based programs, such as KM Club. This study revealed a variety of self-reported health, wellbeing and educational benefits for students, as well as an increase in student's physical activity levels at 2 of the 3 schools participating in the quantitative data collection. This pilot evaluation may help to inform future design, implementation and scale-up of KM Club and school-based health promotion programs, potentially improving child health, wellbeing and educational outcomes.

TRIAL REGISTRATION

(LNR223 - LNR/19/NCC/45).

A scoping review on the implementation of Global Observatory on Physical Activity recommendations for school children in Sub-Saharan Africa

Background: Promoting physical activity (PA) is a critical first step in preventing and lowering the prevalence of non-communicable chronic diseases across all age groups. The Global Observatory on Physical Activity (GoPA) of the World Health Organization (WHO) suggested country-specific guidelines for promoting PA across all age categories to achieve this. However, despite an increase in obesity, there is no information on their compliance for pre-secondary school children in sub-Saharan Africa (SSA). We mapped evidence in the literature and described the available evidence on implementing GoPA recommendations for presecondary school children in SSA. Methods: This scoping review included a search in PubMed, Google Scholar, Scopus, and Cochrane Library with the dates 2013-2020, using keywords and the terms (Physical activity OR exercise AND (GoPA recommendations OR Guidelines) AND ((presecondary school children) OR (primary school children) OR (basic school children) OR (children)). The most important data were tabulated. Results: Twenty-three studies were identified of which ten were eligible for data extraction. Of these ten studies, 2 (20%) were conducted in Nigeria, 4 (40%) in South Africa, 2 (20%) in Ghana and 1(10%) each in Kenya and Senegal were extracted. None of these nations has a national plan or strategy to promote PA and reduce sedentary behaviors (SB). Conclusion: A gap in the formulation of PA guidelines exists in SSA. Urgent action is needed for a national plan or strategy by individual country in SSA to reduce the burden of physical inactivity among school children in SSA.

What factors influence implementation of whole-school interventions aiming to promote student commitment to school to prevent substance use and violence? Systematic review and synthesis of process evaluations

BACKGROUND

Whole-school interventions go beyond classroom health education to modify the school environment to promote health. A sub-set aim to promote student commitment to school to reduce substance use and violence (outcomes associated with low commitment). It is unclear what factors influence implementation of such interventions.

METHODS

We conducted a systematic review including synthesis of evidence from process evaluations examining what factors affect implementation. Meta-ethnographic synthesis was informed by May's General Theory of Implementation.

RESULTS

Sixteen reports, covering 13 studies and 10 interventions were included in our synthesis. In terms of May's concept of 'sense-making', we found that school staff were more likely to understand what was required in implementing an intervention when provided with good-quality materials and support. Staff could sometimes wilfully or unintentionally misinterpret interventions. In terms of May's concept of 'cognitive participation', whereby staff commit to implementation, we found that lack of intervention adaptability could in particular undermine implementation of whole-school elements. Interventions providing local data were reported as helping build staff commitment. School leaders were more likely to commit to an intervention addressing an issue they already intended to tackle. Collaborative planning groups were reported as useful in ensuring staff 'collective action' (May's term for working together) to enact interventions. Collective action was also promoted by the presence of sufficient time, leadership and relationships. Implementation of whole-school interventions took time to build. Considering May's concept of 'reflexive monitoring' (formal or informal review of progress), this was important in assessing and enhancing implementation. 'Quick wins' could help maintain collective impetus to implement further intervention activities.

CONCLUSION

We identified novel factors influencing implementation of whole-school elements such as: local adaptability of interventions; providing local data to build commitment; interventions addressing an issue already on school leaders' agenda; collaborative planning groups; and 'reflexive monitoring' as an explicit intervention component.

Process of youth engagement in school health promotion: a scoping review protocol

INTRODUCTION

School environments are an essential setting to shape and influence the health and well-being of students. Health promoting school (HPS) is a whole-school approach that strengthens and builds a safe and healthy school environment for students to learn and develop. A core component of HPS is the meaningful participation of youth. Despite promising outcomes arising from youth engagement in school health promotion, there is less known on the process of how students are involved in school health promotion and in what form. This scoping review will explore and map the different components of the student engagement process in school health promotion with specific focus on whole-school approaches like HPS.

METHODS AND ANALYSIS

We will follow scoping review guidelines employed by the Joanna Briggs Institute and Arksey and O'Malley's framework. We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to guide reporting. We will follow the PCC mnemonic (participant, concept and context) to develop eligibility criteria. Both published and unpublished literature will be included. Databases to be searched include: CINAHL, ERIC, MEDLINE, Scopus, ProQuest Dissertations & Theses Global databases and Google Scholar. Relevant organisational websites and sources identified by experts will also be reviewed. Two reviewers will screen the title, abstract and full text of the sourced articles. Data from included articles will be charted using a data charting tool. The socioecological model and Hart's Ladder of Participation will be used to guide charting. Descriptive analysis will be conducted for quantitative data, and thematic analysis will be employed for qualitative data. Data will be displayed through tables and narrative descriptions.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. To disseminate our work, we plan to develop an open-access publication, accompanied by a conference presentation and other knowledge translation products.

Evaluation of Social Impact Within Primary School Health Promotion: A Systematic Review

BACKGROUND

Health promotion programs and interventions are designed to encourage behavioral changes in children, encouraging them to make safe and healthy life choices. This systematic review seeks to examine how social impact is measured in primary school health promotion interventions.

METHOD

A systematic search and review process was used to identify and examine primary school health promotion interventions. The PRISMA guidelines were followed to source articles from 6 electronic databases reporting school health promotion programs or interventions in Australia, Canada, New Zealand, or the United Kingdom.

RESULTS

A total of 77 studies were located, representing 55 health promotion interventions delivered in primary school settings. Of these interventions, only 8 (15%) measured or attempted to measure social impact, whereas another 8 (15%) alluded to social impact. The predominant theories reported were social based theories (theories which examine the social influences on people, environments, and behaviors) (n = 17, 59%), with almost a third not informed by an overt health promotion framework or model (n = 34, 59%). A systematic rating system identified some level of stakeholder engagement (n = 30, 53%).

CONCLUSIONS

This systematic review highlights the need for social impact measurement within health promotion to illuminate the role of school programs in delivering lasting change.

Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): protocol for a co-design and feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care

INTRODUCTION

Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection.

METHODS AND ANALYSIS

Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate.

ETHICS AND DISSEMINATION

Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN55416525.

Why do acute healthcare staff engage in unprofessional behaviours towards each other and how can these behaviours be reduced? A realist review protocol

INTRODUCTION

Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people's ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom.

METHODS AND ANALYSIS

This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature.

ETHICS AND DISSEMINATION

Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the 'Evidence Integration Triangle' to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021255490.

Die Bedeutung schulischer Gesundheitsförderung für die Erhöhung gesundheitlicher Chancengleichheit

Sozioökonomisch bedingte Ungleichheiten in der Gesundheit sind ein wichtiges Public-Health-Handlungsfeld und deren Reduzierung eines ihrer wichtigsten Ziele. Bislang ist es jedoch kaum gelungen, gesundheitliche Ungleichheiten zu verringern, was zugleich auch auf ein großes Forschungsdefizit hinweist. Auch im Kindes- und Jugendalter lassen sich bereits Ungleichheiten in der Gesundheit und dem Gesundheitsverhalten feststellen, wobei jene mit einem niedrigen sozioökonomischen Status verglichen mit sozial privilegierteren Gleichaltrigen oftmals mehr Risikofaktoren und gleichzeitig weniger Ressourcen aufweisen. Obwohl Gesundheitsförderung auf gesundheitliche Chancengleichheit abzielt, berücksichtigen Interventionen nur selten den sozioökonomischen Status und können entsprechend wenig Evidenz über sozioökonomisch differenzierte Interventionseffekte liefern. Wie kann es daher gelingen, allen Heranwachsenden die gleichen Chancen auf ein gesundes Aufwachsen zu ermöglichen?

Um der Beantwortung dieser Frage näherzukommen, ist es zum einen das Ziel des Beitrags, einen Überblick über gesundheitliche Ungleichheiten im Kindes- und Jugendalter zu geben und die Rolle von Gesundheitsförderung sowie aktuelle Forschungsdefizite in diesem Zusammenhang aufzuzeigen. Zum anderen soll die Bedeutung der Schule und schulischer Gesundheitsförderungsmaßnahmen bei der Verringerung gesundheitlicher Ungleichheiten und der Erhöhung gesundheitlicher Chancengleichheit herausgestellt werden. Die Schule ist nicht nur ein Ort, an dem Heranwachsende unabhängig von ihrer sozialen Herkunft stets erreicht werden können, sondern hat das Potenzial, gesundheitliche Ungleichheiten sowohl zu verschärfen als auch zu reduzieren.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity

BACKGROUND

This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle.

METHODS

Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias.

RESULTS

Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%).

CONCLUSIONS

These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Do the implementation processes of a school-based daily physical activity (DPA) program vary according to the socioeconomic context of the schools? a realist evaluation of the Active at school program

Background

Less than half of Canadian children meet the Canadian Physical Activity (PA) Guidelines, and the proportion is even lower among children living in underprivileged neighbourhoods. Regular PA supports physical, cognitive, and psychological/social health among school-aged children. Successful implementation of school-based daily physical activity (DPA) programs is therefore important for all children and crucial for children who attend schools in lower socioeconomic settings. The purpose of this study is to uncover what worked, for whom, how, and why during the three-year implementation period of a new “flexible” DPA program, while paying particular attention to the socioeconomic setting of the participating schools.

Methods

This study is a realist evaluation using mixed methods for data generation. Longitudinal data were collected in 415 schools once a year during the three-year implementation period of the program using questionnaires. Data analysis was completed in three steps and included qualitative thematic analysis using a mixed inductive and deductive method and chi-square tests to test and refine context-mechanism-outcome (CMO) configurations.

Results

Giving the school teams autonomy in the choice of strategies appropriate to their context have allowed schools to take ownership of program implementation by activating a community empowerment process, which resulted in a cultural shift towards a sustainable DPA provision in most settings. In rural underprivileged settings, the mobilization of local resources seems to have successfully created the conditions necessary for implementing and maintaining changes in practice. In disadvantaged urban settings, implementing local leadership structures (leader, committee, and meetings) provided pivotal assistance to members of the school teams in providing new DPA opportunities. However, without continued external funding, those schools seem unable to support local leadership structures on their own, jeopardizing the sustainability of the program for children living in disadvantaged urban areas.

Conclusion

By exploring CMO configurations, we have been able to better understand what worked, for whom, how and why during the three-year implementation period of the Active at School! program. When implementing DPA policies, decision makers should consider adjusting resource allocations to meet the actual needs of schools from different backgrounds to promote equal PA opportunities for all children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12797-7.

In It for the Long Haul: RE-AIM Evaluation of a Preschool Programme Implementing and Maintaining Adult-Initiated Motor Skill Development and Physical Activity across a Two-Year Period

Good motor skills (MS) are considered important for children's social, psychological and physical development and general physical activity (PA) levels. The Motor skill in Preschool study (MiPS) aimed to optimize children's MS through weekly PA sessions. The aim of this study is to use the RE-AIM framework to report the two-year implementation process of MiPS since the programme's initiation. Data were collected through a staff questionnaire based on the RE-AIM framework. Data were collected at three months, one year and two years after initiation. Results show that the pedagogical staff believes that the programme promotes MS in children. Implementation measures only showed medium to low fidelity concerning the core element of performing adult-initiated PA sessions with a duration of at least 45 min 4 days a week. The largest barrier was finding the time to plan these PA sessions. Still, the content of the PA sessions achieved high fidelity scores and the programme was deemed suitable for staff's everyday practice and in alignment with the stated pedagogical goals. The mandatory competence development course was highly valued as strong implementation support. It is notable that there is a large variation in the implementation among the preschools with some struggling more than others.

Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review

Background

Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors.

Methods

A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed.

Results

Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture).

Conclusions

The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs.

Registration

PROSPERO, #CRD42019133251.

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.

Sintra Grows Healthy: development and implementation of a food literacy curriculum for primary schools

OBJECTIVE

Describe the process of development and implementation of Health at the Table - a food literacy curriculum for primary school aged children.

DESIGN

Through a community-based research process, Health at the Table development and implementation took place in four stages: exploratory study, production, implementation and monitoring.

SETTING

Primary schools of Sintra's municipality, Portugal.

PARTICIPANTS

Children (6-10 years), teachers, school staff and children's legal guardians of three primary schools during the pilot project and eight primary schools in the second year.

RESULTS

During the needs assessment phase, 99·1 % (n 341) of the children's legal guardians, 100 % (n 34) of the teachers and 100 % (n 19) of the school staff considered that the school plays an important or very important role in children's food literacy (stage 1). During the pilot project, a manual with sixty session plans was developed (stage 2). In the second year, Health at the Table was implemented by seventy-two trained teachers during one school year (stage 3). Most of the teachers agreed that the curriculum was appropriate (69·2 %) and that children developed health, wellness/well-being and environmental skills (83·1 %). Most of the children said they had learned about healthy eating (86·3 %) and claimed to eat healthier since the Health at the Table implementation (58·9 %) (stage 4).

CONCLUSIONS

Health at the Table is a food literacy curriculum that can be reproduced in similar contexts in a sustainable way. The need to combine educational strategies with a healthy school food environment is reinforced to increase effectiveness in tackling childhood obesity.

The Role of Local Leaders in the Implementation of Adult-Initiated Motor Skill Development and Physical Activity in Preschool-A Case Study

Good motor skills (MS) and physical activity (PA) are considered important for children’s physical, social, and psychological development. The Motor skills in PreSchool (MiPS) study-Denmark aimed to optimize children’s MS through weekly PA sessions. The aim of this paper is to explore the role of local preschool leaders and their strategies in influencing the implementation of MiPS into daily practice. Leaders from all seven preschools in the project were interviewed. The results show that preschool leaders used communication (setting an agenda and dedicating speaking time to address the program at staff meetings) and reflective questioning about the pedagogic staff’s current practice in relation to the program (adding focus on MS and PA) as their main course of action. Through this form of communication and reflective questioning, the preschool leaders aimed to involve the staff and heighten their sensemaking in the existing practice while also ensuring that the implementation of the program was kept in progress. In sum, future implementation of an MS and PA initiative in preschools should put emphasis on a shared responsibility between leaders and staff combined with an adaptive approach in which the existing practice is reshaped rather than just increasing the workload of the pedagogic staff.

A Rapid Realist Review of Effective Mental Health Interventions for Individuals with Chronic Physical Health Conditions during the COVID-19 Pandemic Using a Systems-Level Mental Health Promotion Framework

The 2020 global outbreak of COVID-19 exposed and heightened threats to mental health across societies. Research has indicated that individuals with chronic physical health conditions are at high risk for suffering from severe COVID-19 illness and from the adverse consequences of public health responses to COVID-19, such as social isolation. This paper reports on the findings of a rapid realist review conducted alongside a scoping review to explore contextual factors and underlying mechanisms or drivers associated with effective mental health interventions within and across macro-meso-micro systems levels for individuals with chronic physical health conditions. This rapid realist review extracted 14 qualified studies across 11 countries and identified four key mechanisms from COVID-19 literature-trust, social connectedness, accountability, and resilience. These mechanisms are discussed in relation to contextual factors and outcomes reported in the COVID literature. Realist reviews include iterative searches to refine their program theories and context-mechanism-outcome explanations. A purposive search of pre-COVID realist reviews on the study topic was undertaken, looking for evidence of the robustness of these mechanisms. There were differences in some of the pre-COVID mechanisms due to contextual factors. Importantly, an additional mechanism-power-sharing-was highlighted in the pre-COVID literature, but absent in the COVID literature. Pre-existing realist reviews were used to identify potential substantive theories and models associated with key mechanisms. Based on the overall findings, implications are provided for mental health promotion policy, practice, and research.

Exploring implementation of a nationwide requirement to increase physical activity in the curriculum in Danish public schools: a mixed methods study

BACKGROUND

In 2014, the Danish Government introduced a wide-ranging school reform that applied to all public schools in Denmark. A distinctive feature of the reform was that it became mandatory to implement an average of 45 min of daily physical activity within the curriculum. Using the RE-AIM framework as an evaluation tool, the objective of the current study was to evaluate the reach, effectiveness, adoption, implementation, and maintenance of mandatory physical activity within the curriculum at ten Danish schools.

METHODS

A complementary mixed-methods approach using accelerometers, questionnaires, and semi-structured interviews was conducted. A total of 10 schools were invited to participate, including 846 students, 76 teachers, and 10 school managers on various levels. Students were invited to wear an accelerometer for seven consecutive days. Teachers were invited to participate in a questionnaire, and school managers were encouraged to take part in a semi-structured interview.

RESULTS

Results showed that, on average, 45.2% of the students were active at least 45 min daily within the curriculum. Teacher and school management interest in physical activity, competencies development, and shared decision-making were identified as central factors for adoption of the requirement. Scheduling physical activity within scheduels and collaborations with external parties were found to influence implementation. Finally, internal coordination, motivated school staff, and school management priority were identified as central factors for maintenance.

CONCLUSIONS

This study provides an evaluation on a nationwide physical activity requirement in Danish public schools. When introducing a wide-ranging nation-wide requirement on physical activity within the curriculum, school managers need to prioritize and support the implementation process. Teachers need to be involved in the decision processes in order to ensure motivation and local ownership. The study also highlights the benefits of an internal coordinator as well as development of a shared strategy among schools, municipalities, and other stakeholders in order to succeed with the implementation.

Implementing a set of health promoting processes in English secondary schools: A comparative case study

Objective

To understand the enablers and barriers to implementing a set of adaptive processes aimed at supporting secondary schools to reflect on and subsequently address how they could adjust school practices, culture and the environment to create a whole school approach to promoting healthy lifestyles.

Study design

A qualitative, comparative case study.

Methods

Two in depth case studies were created of two purposefully selected schools in low socio-economic areas of South West England. Data were collected via meetings, observations, field notes, interviews and audit. Interviews were transcribed verbatim. Individual thematic analyses were conducted for each school and a comparative analysis approach was used to understand the barriers and enablers across both cases.

Results

Schools were supported to use a health-promoting lens and identify feasible improvements through an adaptive and context specific process. The school environment and ethos were identified as the areas where schools could conceive the most adjustments to enhance the promotion of healthy lifestyle choices. With the lack of government policy for health promotion in schools (HPS), the Head teacher's approach to health was key to making meaningful changes.

Conclusions

Health promoting school approaches need to be adaptive to local context, actively involve community partners and link to local initiatives where possible, with support from Head teachers and business managers. Starting with what teachers, pupils and parents see as the barriers to health can create a whole school ethos for broad reaching and sustainable HPS programmes.

Using Process Evaluation Results to Compare Peer and Adult Leader Delivery of the PAWS (Peer-Education about Weight Steadiness) Club Program

To date, there is limited published literature on process evaluation of adolescent health promotion programs. In this paper, we describe the methods and results of PAWS Club process evaluation over 2 years of implementation to compare the effectiveness of delivery by peer and adult leaders. PAWS (Peer-education About Weight Steadiness) Club was a 12-week healthy lifestyle program, delivered to 6th and 7th graders by peer and adult educators, using cluster randomized controlled design. Peer educators were 8th graders in the program schools and adult educators were staff/teachers in the program schools. Trained university students filled out fidelity logs at each session led by peer and adult educators to assess program delivery. The fidelity logs included questions to collect information about the number of participants, duration of the session, percent of activities completed, and if lessons started on time, lesson objectives were clearly stated, lesson objectives were emphasized, demonstrations were visible to participants, all activities were completed, the leader was familiar with lessons, the leader maintained an appropriate pace, the leader kept participants on track, and the leader asked if participants had any questions. Adult educators had a higher mean performance for all questions compared to peer leaders. Significant differences were observed for emphasizing lesson objectives (p = 0.005), making demonstrations visible to participants (p = 0.031), being familiar with the lesson plan (p = 0.000), maintaining an appropriate pace (p = 0.000), keeping participants on track (p = 0.000), and asking if participants had any questions (p = 0.000). Significance was set at p < 0.05. Findings from the current study have implications for designing and conducting a process evaluation of complex healthy lifestyle programs with adolescents in schools. Additional training of peer educators may be needed to enhance program delivery.

Exploring Factors Contributing to the Implementation of Ontario's Healthy Kids Community Challenge: Surveys and Key Stakeholder Interviews with Program Providers

(1) Background: To explore factors contributing to the Healthy Kids Community Challenge (HKCC) program implementation; (2) Methods: Data were collected through a quantitative survey (n = 124) and in-depth telephone interviews (n = 16) with program providers. Interviews were recorded and transcribed for thematic analysis using NVivo; (3) Results: Provincial funding and in-kind support from community partners were key. Initiatives were feasible to implement, and key messages were well-received by communities. Specific practices and process were commonly discussed, and strong local program leadership was crucial to implementation; (4) Conclusions: Results have implications for planning and implementing future multi-component, community-based health promotion programs that include similar partnerships.

An Animation- Versus Text-Based Computer-Tailored Game Intervention to Prevent Alcohol Consumption and Binge Drinking in Adolescents: Study Protocol

The purpose of this paper is to describe the protocol for the design, implementation, and evaluation of an animation- versus text-based computer tailoring game intervention aimed at preventing alcohol consumption and binge drinking (BD) in adolescents. A cluster-randomized controlled trial (CRCT) is carried out in students aged 14-19 enrolled in 24 high schools from Andalusia (Spain), which are randomized either to experimental (EC-1, EC-2) or waiting-list control conditions (CC). EC-1 receives an online intervention (Alerta Alcohol) with personalized health advice, using textual feedback and several gamification techniques. EC-2 receives an improved version (Alerta Alcohol 2.0) using animated videos and new gamification strategies. Both programs consist of nine sessions (seven taking place at high school and two at home): session 1 or baseline, sessions 2 and 3 that provide tailored advice based on the I-Change Model; sessions 4, 5, 7, and 8 are booster sessions, and sessions 6 and 9 are follow-up questionnaires at six and twelve months. The CC completes the baseline and the evaluation questionnaires. The primary outcome is BD within 30 days before post-test evaluations, and as secondary outcomes we assess other patterns of alcohol use. The findings should help the development of future alcohol drinking prevention interventions in adolescents.

Health promotion in secondary schools: participatory process for constructing a self-assessment tool

This article presents the process of constructing an effective self-assessment tool for monitoring health promotion in secondary schools (SS). The ultimate aim is to improve adolescents' well-being and quality of life in their reference environment. The design and validation of the instrument were based on participatory action research (involving students, professors, parents, health professionals, youth workers, youth directors, youth managers). A mixed quantitative and qualitative approach was adopted. The construction process included the following five consecutive stages: (i) steering-group creation and definition of objectives; (ii) diagnosing students' health and well-being in SS (case study); (iii) initial design and construction of health promotion indicators; (iv) validation based on expert judgement and (v) validation by means of a pilot test. The final construction of the self-assessment tool included 5 areas (healthy habits, affectivity and socialization, emotional well-being, safety and risks, and specific health situations), 9 objectives and 18 indicators deployed through a rubric. Each indicator is discussed in depth, specifying the most appropriate resources and health promotion activities for its application. The final self-assessment tool is designed to be sensitive to and effective for self-assessment of health promotion in SS. It contributes to improving adolescent health on an individual basis and also has an impact on the school environment. Finally, it also promotes analysis of the health content on the curriculum and the teaching-learning method(s) employed at the school. The self-assessment tool has been published open access and its implementation will continue to increase health promotion in SS in Catalonia.

Considerations for Individual-Level Versus Whole-School Physical Activity Interventions: Stakeholder Perspectives

Strategies to address declining physical activity levels among children and adolescents have focused on ‘individual-level’ approaches which often fail to demonstrate impact. Recent attention has been on an alternative ‘whole-school’ approach to increasing physical activity that involves promoting physical activity throughout all aspects of the school environment. There is, however, a lack of evidence on how whole-school physical activity approaches could be implemented in the UK. This qualitative study explored perspectives of key stakeholders on potential reasons for the lack of impact of individual-level school-based interventions on children’s physical activity, and key considerations for adopting a whole-school approach. Nineteen semi-structured interviews were conducted with a range of stakeholders involved in the implementation of physical activity programmes in UK schools. Data were analysed using an inductive approach. Respondents suggested that individual-level school-based interventions to increase physical activity often failed to consult end users in the design and were typically implemented in environments unsupportive of long-term change. They subsequently outlined specific barriers and key facilitators for the adoption and implementation of whole-school approaches in UK settings and recommended a shift in research foci towards building an evidence base around educational outcomes and whole-school implementation insights.

Implementation of preventive measures to prevent COVID-19: a national study of English primary schools in summer 2020

We examined the feasibility of implementing preventive measures to prevent SARS-CoV-2 transmission across 105 English primary schools in summer 2020 via a survey and interviews with headteachers. High rates of implementation of most recommended measures were noted with the exception of requiring 2 m distance for students, fitting hand sanitizers in classrooms and introducing one-way systems in school corridors. Measures such as regular handwashing and stopping assemblies were considered easy to implement. Majorly challenging measures included distancing between individuals (for students: 51%, N = 99; for staff: 34%; N = 98; for parents: 26%, N = 100), spacing out desks (34%, N = 99), keeping same staff assigned to each student group (33%, N = 97) and staggering break times (25%, N = 99). Rapid implementation was facilitated by staff commitment and communication among stakeholders, but hampered by limitations with guidance received, physical environments, resources, parental adherence and balancing preventive measures with learning. Difficulties with distancing for younger children suggest that smaller bubbles with fewer distancing requirements within these may be a policy option. Schools require further financial, human resource and other support for effective implementation of preventive measures.

Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain

BACKGROUND

Schools are key settings for delivering mental illness prevention in adolescents. Data on stakeholders' attitudes and factors relevant for the implementation of Internet-based prevention programmes are scarce.

METHODS

Stakeholders in the school setting from Austria and Spain were consulted. Potential facilitators (e.g. teachers and school psychologists) completed an online questionnaire (N=50), policy makers (e.g. representatives of the ministry of education and health professional associations) participated in semi-structured interviews (N=9) and pupils (N=29, 14-19 years) participated in focus groups. Thematic analysis was used to identify experiences with, attitudes and needs towards Internet-based prevention programmes, underserved groups, as well as barriers and facilitators for reach, adoption, implementation and maintenance.

RESULTS

Experiences with Internet-based prevention programmes were low across all stakeholder groups. Better reach of the target groups was seen as main advantage whereas lack of personal contact, privacy concerns, risk for misuse and potential stigmatization when implemented during school hours were regarded as disadvantages. Relevant needs towards Internet-based programmes involved attributes of the development process, general requirements for safety and performance, presentation of content, media/tools and contact options of online programmes. Positive attitudes of school staff, low effort for schools and compatibility to schools' curriculum were seen as key factors for successful adoption and implementation. A sound implementation of the programme in the school routine and continued improvement could facilitate maintenance of online prevention initiatives in schools.

CONCLUSIONS

Attitudes towards Internet-based mental illness prevention programmes in school settings are positive across all stakeholder groups. However, especially safety concerns have to be considered.

Using community-led development to build health communication about rheumatic heart disease in Aboriginal children: a developmental evaluation

OBJECTIVE

A high prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Aboriginal children in northern Australia is coupled with low understanding among families. This has negative impacts on children's health, limits opportunities for prevention and suggests that better health communication is needed.

METHODS

During an RHD echocardiography screening project, Aboriginal teachers in a remote community school created lessons to teach children about RHD in their home languages, drawing on principles of community-led development. Access to community-level RHD data, previously unknown to teachers and families, was a catalyst for this innovative work. Careful, iterative discussions among speakers of four Aboriginal languages ensured a culturally coherent narrative and accompanying teaching resources.

RESULTS

The evaluation demonstrated the importance of collective work, local Indigenous Knowledge and metaphors. As a result of the lessons, some children showed new responses and attitudes to skin infections and their RHD treatment. Language teachers used natural social networks to disseminate new information. A community interagency collaboration working to prevent RHD commenced. Conclusions and implications for public health: Action to address high rates of RHD must include effective health communication strategies that value Indigenous Knowledge, language and culture, collaborative leadership and respect for Indigenous data sovereignty.

Study of health information needs among adolescents in Croatia shows distinct gender differences in information seeking behaviour

BACKGROUND

Understanding the health information needs of adolescents is the first step towards providing them with relevant information to aid them in their decision making regarding health issues.

OBJECTIVE

The goal of this study is to assess adolescents' needs, perceptions and sources of health information.

METHODS

Four hundred sixty-nine high school students in Osijek, Croatia, participated in this study by answering a questionnaire. The collected data were analysed using basic frequency and non-parametric statistical methods.

RESULTS

The most popular health topics identified by adolescents in our study were nutrition, diseases, depression, relationships, sexual intercourse and alcohol. Adolescents consider their parents the most reliable personal source of health information (72.0%), while they perceive the Internet as the main non-personal source of health information (29.8%). Adolescents wish to get more education about health issues at school (54.4%). Significant gender differences were found in adolescents' needs, perceptions and sources of health information.

CONCLUSIONS

It is important to provide adolescents with systematic institutional health education and improve health advisory services and library/information services to assist adolescents in locating health information and resolving their health related questions.

Are Danish vocational schools ready to implement "smoke-free school hours"? A qualitative study informed by the theory of organizational readiness for change

BACKGROUND

The smoking prevalence is high among students enrolled in vocational education and training, which is considered a lower level of education. The school tobacco policy regarding smoke-free school hours stipulates that students and staff are not allowed to smoke during school hours-inside or outside school premises-and it might be an effective intervention for reducing smoking in vocational schools. For school tobacco policies to be effective, they must be appropriately implemented. A primary predictor for successful implementation is organizational readiness for change. This study seeks to identify and understand the barriers to and facilitators for developing organizational readiness to implement smoke-free school hours in Danish vocational schools.

METHODS

Semi-structured interviews and focus groups were carried out with managers and teachers (n = 22 participants) from six vocational schools. The interview guides were informed by "A theory of organizational readiness for change" developed by Weiner, which was also used as a framework to analyze the data.

RESULTS

We identified 13 facilitators and barriers. Nine factors acted as facilitators, including the following: believing that health promotion is a school role and duty; believing that society and workplaces are becoming more smoke-free, and believing that smoke-free school hours is a beneficial strategy to achieve fewer educational interruptions. Additional facilitators include establishing clear rules for sanctioning and enforcement, developing a joint understanding about smoke-free school hours, developing skills to deal with student responses to smoke-free school hours, establishing social alternatives to smoking, offering smoking cessation help, and mandating smoke-free school hours by law. Four organizational norms, practices, or discourses acted as barriers: believing that smoke-free school hours violate personal freedom, believing that students have more important problems than smoking, believing that it is difficult to administer the level of enforcement, and believing that the enforcement of smoke-free school hours negatively influences student-teacher relations.

DISCUSSION

Our results suggest that developing organizational readiness before adopting a comprehensive tobacco policy such as smoke-free school hours is important for successful implementation. Further research should investigate how to strengthen the facilitators for and counter the barriers to developing readiness for implementing smoke-free school hours.

Social inequalities in availability of health-promoting interventions in Québec elementary schools

Availability of health-promoting interventions (HPIs) may vary across schools serving students with different socioeconomic backgrounds. Our objectives were to describe social inequalities across elementary schools in: (i) level of importance that school principals attribute to 13 common health-related issues among students in their school; (ii) availability of HPIs within their school addressing eight health topics and (iii) (mis)alignment between perceived importance and HPI availability. Data were collected in telephone interviews with school principals in a convenience sample of 171 elementary schools (59% of 291 schools contacted). Schools were categorized as serving very advantaged, moderately advantaged or disadvantaged students. Principals reported how important 13 health issues were among students in their schools and provided data on HPI availability for 8 health issues, 4 of which required school action under government mandates. Higher proportions of principals in schools serving disadvantaged students (36% of all 171 schools) perceived most health issues as important. The mean number of HPIs in the past year was 12.0, 12.1 and 11.7 in schools serving very advantaged, moderately advantaged and disadvantaged students, respectively. Only availability of mental health HPIs differed by school deprivation (60, 43 and 30% in very, moderately and disadvantaged, respectively). Although most schools offered oral health HPIs, dental problems were not perceived as important. Smoking was perceived as not important and smoking-related HPIs were relatively rare (9%). Given rapid evolution in public health priorities, (mis)alignment between perceived importance of specific health issues and HPI availability in elementary schools warrants ongoing reflection.

Lessons learnt from the field: a qualitative evaluation of adolescent experiences of a universal mental health education program

teen Mental Health First Aid (teenMHFA) is a school-based mental health program that trains adolescents to support peers who are experiencing mental health problems or crises. The program has been evaluated for adolescents aged 15-18 years as part of a randomized controlled trial, however qualitative feedback from students on their perceptions of the program is yet to be explored. The current study describes the perspectives of students who took part in the trial. Feedback on the perceived strengths and weaknesses of the program was provided by 979 Year 10 students (M = 15.82 years, female = 43.94%, English as a first language = 72.77%) at four government funded public schools in Melbourne, Australia via online surveys. A content and thematic analysis was performed on the data using a six-step process. Students generally found the program relevant and they connected with the visual material, personal stories and interactive activities. Suggestions for improvements included encouraging active student participation in classroom discussion and providing opportunities to practice skills. School-based mental health education can benefit from input from stakeholder perspectives, particularly when designing mental health content for delivery by external trainers.

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.

Health Literacy in Schools? A Systematic Review of Health-Related Interventions Aimed at Disadvantaged Adolescents

Socioeconomically disadvantaged populations are at greater risk of adopting unhealthy behaviours and developing chronic diseases. Adolescence has been identified as a crucial life stage to develop lifelong healthy behaviours, with schools often suggested as the ideal environment to foster healthy habits. Health literacy (HL) provides a possible solution to promote such healthy behaviours. The aim of this study was to review school-based HL-related interventions targeting socioeconomically disadvantaged adolescents and to identify effective intervention strategies for this population. Searches were performed in six databases. Inclusion criteria included age: 12–16; the implementation of a school-based intervention related to HL aimed at socioeconomically disadvantaged populations; an intervention focused on: physical activity (PA), diet, mental health, substance abuse or sleep. Forty-one articles were included, with the majority focusing on PA and diet (n = 13), PA (n = 9) or mental health (n = 7). Few interventions focused solely on substance abuse (n = 2) or sleep (n = 1), and none targeted or assessed HL as an outcome measure. There was huge heterogeneity in study design, outcomes measures and effectiveness reported. Effective intervention strategies were identified that can be used to guide future interventions, including practical learning activities, peer support and approaches targeting the school environment, the parents or that link the intervention to the community.

Evaluating the health promoting schools in Iran: across-sectional study

Purpose

Health-promoting schools have been associated with improvements in the health status of students globally. This study is a secondary analysis study assessing Iranian HPSs.

Design/methodology/approach

This was a cross-sectional study on routinely collected data using an external audit 63-item checklist, which was utilized to evaluate 440 HPSs between 2014 and 2017. The mean score for each of the checklists' components was calculated. Nonparametric tests were conducted to investigate the association between the presence of a school caregiver, students' educational level and the school's score.

Findings

While the number of five- and four-star schools increased significantly, one- to three-star schools declined. Providing clinical and counseling services had negative growth. Despite the steady growth of the staff's health, this category still had the lowest score among; on the contrary, physical activity had the highest score in 2017. The presence of a full-time school caregiver and middle schools were both significantly correlated with achieving higher scores (p < 0.005).

Originality/value

It seems that in addition to developing school facilities to promote physical activities, measures should be taken to promote access to counseling services, considering health issues of students and staff and finally increasing the number of full-time school caregiver

Rapid Realist Review of School-Based Physical Activity Interventions in 7- to 11-Year-Old Children

Meta-analysis of physical activity interventions in school settings have revealed low efficacy and that there is a need to explore implementation fidelity. The aim of this rapid realist review was to determine, what physical activity interventions in school settings for children aged 7- to 11-years-old works, for whom, and in what circumstances. The realist synthesis was conducted following RAMESES guidelines. Relevant studies were identified following a systematic search process and data from 28 studies was extracted for evidence to form context-mechanism-outcome configurations that were clustered and refined. Using the five-level socioecological model, the program theories were classified into the levels of intrapersonal (child), interpersonal (teachers), institutional (program content, school administration, and school environment), community (home and neighborhood), and policy. The school level led to most context-mechanism-outcome configurations related to school leadership and policy, workforce structure, program characteristics, and school environment. At each level, we identified features of interventions, alongside implementation considerations that might work to promote efficacy and sustainability. The need to recognize the school environment as part of a complex system with multi-level interaction and influences was a key finding. In line with realist philosophy, the researchers encouraged primary research to confirm, refute, and refine the program theories presented.