Unravelling the Effects of the Healthy Primary School of the Future: For Whom and Where Is It Effective?

School Health Promotion, the Body Mass Index z-Score, and Psychosocial Health in Primary Schools of the Netherlands

Childhood overweight and psychosocial issues remain significant public health concerns. Schools worldwide implement health promotion programs to address these issues and to support the physical and psychosocial health of children. However, more insight is needed into the relation between these health-promoting programs and the Body Mass Index (BMI) z-score and psychosocial health of children, while taking into account how school factors might influence this relation. Therefore, we examined whether the variation between primary schools regarding the BMI z-score and psychosocial health of students could be explained by school health promotion, operationalized as Healthy School (HS) certification, general school characteristics, and the school population; we also examined to what extent the characteristics interact. The current study had a repeated cross-sectional design. Multilevel analyses were performed to calculate the variation between schools, and to examine the association between HS certification and our outcomes. Existing data of multiple school years on 1698 schools were used for the BMI z-score and on 841 schools for psychosocial health. The school level explained 2.41% of the variation in the BMI z-score and 2.45% of the variation in psychosocial health, and differences were mostly explained by parental socioeconomic status. Additionally, HS certification was associated with slightly lower BMI z-scores, but not with psychosocial health. Therefore, obtaining HS certification might contribute to the better physical health of primary school students in general. This might indicate that HS certification also relates to healthier lifestyles in primary schools, but further research should examine this.

Does School Health Promotion Have Additional Value for Educational Performance? A Repeated Cross-Sectional Multilevel Study

Little information is available regarding the influence of the interplay between the school context and school health promotion on educational performance. Therefore, we examined whether the variation between primary and secondary schools regarding the educational performance of students could be explained by general school characteristics, school population characteristics, and school health promotion and to what extent these factors interact. We performed multilevel analyses using existing data on 7021 primary schools and 1315 secondary schools in the Netherlands from the school years 2010-2011 till 2018-2019. Our outcomes were the final test score from primary education and the average grade of standardized final exams from secondary education. School health promotion was operationalized as having obtained Healthy School (HS) certification. For the test score, 7.17% of the total variation was accounted for by differences at the school level and 4.02% for the average grade. For both outcomes, the percentage of disadvantaged students in a school explained most variation. HS certification did not explain variation, but moderated some associations. We found small to moderate differences between schools regarding educational performance. Compositional differences of school populations, especially socioeconomic status, seemed more important in explaining variation in educational performance than general school characteristics and HS certification. Some associations were moderated by HS certification, but differences remained small in most cases.

Effectiveness of School-Based Interventions in Europe for Promoting Healthy Lifestyle Behaviors in Children

The objective of this narrative review was to summarize existing literature on the effectiveness of school-based interventions, implemented in Europe, under the aim of promoting healthy lifestyle behaviors in children (6-10 years old). A search of PubMed, Scopus, EFSA and Google Scholar databases was performed for studies published from January 2016 to June 2022. Specific search terms and exclusion criteria were used. Based on the results, diet and physical activity interventions had favorable effects on a series of health outcomes, including anthropometric parameters, biomarkers, eating behavior and self-efficacy. Diet-only interventions had a positive impact specifically on eating habits, mostly on water consumption. Most successful interventions lasted for 1 school year, and they were characterized by parental involvement and teachers' training.

Effectiveness of School-Based Interventions in Europe for Promoting Healthy Lifestyle Behaviors in Children

The objective of this narrative review was to summarize existing literature on the effectiveness of school-based interventions, implemented in Europe, under the aim of promoting healthy lifestyle behaviors in children (6-10 years old). A search of PubMed, Scopus, EFSA and Google Scholar databases was performed for studies published from January 2016 to June 2022. Specific search terms and exclusion criteria were used. Based on the results, diet and physical activity interventions had favorable effects on a series of health outcomes, including anthropometric parameters, biomarkers, eating behavior and self-efficacy. Diet-only interventions had a positive impact specifically on eating habits, mostly on water consumption. Most successful interventions lasted for 1 school year, and they were characterized by parental involvement and teachers' training.

"Mummy, Can I Join a Sports Club?" A Qualitative Study on the Impact of Health-Promoting Schools on Health Behaviours in the Home Setting

Information regarding school-based health-promoting interventions' potential effects in the home environment is scarce. Gaining more insight into this is vital to optimise interventions' potential. The Healthy Primary School of the Future (HPSF) is a Dutch initiative aiming to improve children's health and well-being by providing daily physical activity sessions and healthy school lunches. This qualitative study examines if and how HPSF influenced children's and parents' physical activity and dietary behaviours at home. In 2018-2019, 27 semi-structured interviews were conducted with parents from two HPSFs. Interviews were recorded and transcribed, and data were coded and interpreted through thematic analysis. HPSF resulted in various behavioural changes at home, initiated by both children and parents. Parents reported improvements in healthy behaviours, as well as compensatory, unhealthy behaviours. Reasons for behavioural change included increased awareness, perceived support to adopt healthy behaviours, and children asking for the same healthy products at home. Barriers to change included no perceived necessity for change, lack of HPSF-related information provision, and time and financial constraints. Both child-to-adult intergenerational learning and parent-initiated changes play an important role in the transfer of health behaviours from school to home and are therefore key mechanisms to maximise school-based health-promoting interventions' impact.

The Effects of the Healthy Primary School of the Future on Children's Fruit and Vegetable Preferences, Familiarity and Intake

Mere exposure is an often-described strategy to increase children’s food familiarity, preferences, and intake. Research investigating this method in less controlled settings is scarce. This study investigates the effects of repeated fruit and vegetable (FV) exposure through the Healthy Primary School of the Future (HPSF) on children’s FV familiarity, preferences, and intake. The study had a longitudinal quasi-experimental design comparing two full HPSFs (focus: nutrition and physical activity) with two partial HPSFs (focus: physical activity) in the Netherlands. Annual measurements (child-reported questionnaires) were conducted during 2015–2019 in 833 7–12-year-old children. The study was registered on ClinicalTrials.gov (NCT02800616). After correction for baseline, full HPSFs had, on average, a lower number of unfamiliar vegetable items after one (effect size (ES) = −0.28) and three years (ES = −0.35) and a higher number of disliked vegetable items after one year (ES = 0.24) than partial HPSFs. Unfavorable intervention effects were observed for fruit intake after one (odds ratio (OR) = 0.609) and four years (OR = 0.451). Repeated FV exposure had limited effects on children’s FV familiarity, preferences, and intake, likely due to insufficient taste exposure. Considering the widespread implementation of school-based mere exposure efforts, it is highly relevant to further investigate under which circumstances mere exposure effectively contributes to improvements in (determinants of) FV intake.

BMI trajectories after primary school-based lifestyle intervention: Unravelling an uncertain future. A mixed methods study

This mixed methods study aimed to examine plausible body mass index (BMI) trajectories after exposure to a primary school-based lifestyle intervention to aid in estimating the long-term intervention benefits. BMI trajectories for children at control schools (mean 7.6 years of age) were modelled until 20 years of age through extrapolating trial evidence (N = 1647). A reference scenario assumed that the observed 2-year effects of the 'Healthy Primary Schools of the Future' (HPSF) and 'Physical Activity Schools' (PAS) were fully maintained over time. This was modelled by applying the observed 2-year BMI effects until 20 years of age. Expert opinions on likely trends in effect maintenance after the 2-year intervention period were elicited qualitatively and quantitatively, and were used for developing alternative scenarios. Expert elicitation revealed three scenarios: (a) a constant exposure-effect and an uncontrolled environment with effect decay scenario, (b) a household multiplier and an uncontrolled environment with effect decay scenario, and (c) a household multiplier and maintainer scenario. The relative effect of HPSF at 20 years of age was -0.21 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a) to -0.06 kg/m2 (b), and -0.50 kg/m2 (c). For PAS, the relative effect was -0.17 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a, b), to -0.21 kg/m2 (c). The mixed methods approach proved to be useful in modelling plausible BMI trajectories and specifying uncertainty on effect maintenance. Further observations until adulthood could reduce the uncertainty around future benefits. This trial was retrospectively registered at Clinicaltrials.gov (NCT02800616).