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1.  The development, feasibility and acceptability of a school-based obesity prevention programme: results from three phases of piloting 
BMJ Open  2011;1(1):e000026.
Objectives
To develop a school-based obesity prevention programme and evaluate the feasibility and acceptability of the intervention and the planned definitive cluster randomised trial.
Design
This was a three stage pilot involving six schools (398 children) in South West England, including an exploratory randomised controlled trial and qualitative interviews and focus groups with teachers, parents and children.
Intervention
The Healthy Lifestyle Programme uses a range of school-based activities including lessons, assemblies, parents' evenings, interactive drama workshops and goal setting to engage schools, children and their families.
Results
Of the 398 eligible children in the three pilot phases, only four opted out and a further three withdrew from the exploratory trial. In the exploratory trial, baseline measurements (anthropometric and behavioural) were obtained for 202/204 eligible children in four schools and both 18- and 24-month outcome measurements for 193/204 and 187/204 participants, respectively. Qualitative data show that delivery of the intervention is feasible within schools and acceptable to teachers, children and families. In the exploratory trial, 18/80 children (24%) in the intervention schools and 31/122 (26%) in the control schools were overweight or obese at baseline, increasing, at 18-month follow-up, to 38/119 (32%) in the control schools compared with 18/74 (24%) in the intervention schools. At 24 months the proportion of overweight and obese children in the control schools remained at 32% (36/114), whereas the proportion in the intervention schools decreased slightly to 22% (16/73).
Conclusion
The Healthy Lifestyle Programme is feasible to deliver and acceptable to schools, children and their families. We recruited, retained and obtained outcome measurements from 92% of eligible children in the exploratory trial, including measurements taken after transition to secondary school, suggesting that a definitive trial is likely to be deliverable.
Article Summary
Article focus
To show the development and evaluation of a novel school-based obesity prevention programme through three detailed stages of piloting.
To demonstrate the acceptability of the Healthy Lifestyle Programme (HeLP) to schools, children and their families.
To present evidence showing the feasibility of the trial design and outcome measurements through an exploratory trial involving four schools and 202 children.
Key messages
HeLP has been systematically developed and uses drama-based activities to engage the school, children and their families in healthy lifestyle messages and activities.
The programme has been piloted in six schools involving 398 children and results suggest that it is acceptable and feasible for schools, children and their families.
Results from the pilot phases have provided sufficient evidence to support the evaluation of the HeLP intervention in a full scale trial.
Strengths and limitations of this study
Strengths
The HeLP intervention has undergone a systematic development process using research evidence, behavioural theory, stakeholder consultation and piloting. This has enabled the researchers to gain a deeper understanding of the context in which the intervention is to be delivered in order to maximise engagement at all levels. Preliminary results suggest the programme may affect behaviours associated with overweight and obesity.
Limitations
Interviews and focus groups were conducted by the lead researcher who had built up a relationship with the schools, children and their families. This may have affected responses as the participants might not have wanted to express negative opinions. However, the ongoing support and retention of the schools and children would suggest that if there was such an effect, it was very slight. Piloting has taken place in schools in varying socioeconomic areas, and although there is a limited ethnic mix of children in South West England, the drama framework has been specifically developed to allow flexibility and adaptation to ensure it is recognising and responding to the needs of the children receiving it.
doi:10.1136/bmjopen-2010-000026
PMCID: PMC3191390  PMID: 22021732
2.  A qualitative study of the views of adolescents on their caries risk and prevention behaviours 
BMC Oral Health  2015;15:141.
Background
The purpose of this study was to explore the attitudes and beliefs of adolescents towards dental caries and their use or non-use of caries prevention regimens.
Methods
Adolescents aged 16 years from four state-funded secondary schools in North West of England (n = 19). Purposive sampling strategically selected participants with characteristics to inform the study aims (gender, ethnicity, and caries status). Semi-structured interviews were transcribed verbatim and analysed using a framework approach.
Results
14 codes within five overarching themes were identified: “Personal definition and understanding of oral health”; “Knowledge of oral health determinants”; “Influences on oral health care”; Reason for oral health behaviours”; and “Oral health in the future”. Adolescents conceptualise oral health as the absence of oral pathology and the ability to function, which included an aesthetic component. Appearing to have healthy teeth was socially desirable and equated with positive self-image. The dominant influence over oral health behaviours was habitual practice encouraged by parents from a young age, with limited reinforcement at school or by dental practices. At this transitional age, participants recognised the increasing influence of peers over health behaviours. Self-efficacy pertained to diet modification (reduction in sugar-ingestion) and oral hygiene behaviour (tooth-brushing). A lack of understanding of caries aetiology was evident. Behaviours were mitigated by a lack of environmental support; and a desire for immediate gratification often overcame attempts at risk-reducing behaviour.
Conclusions
Parents primarily influence the habitual behaviours of adolescents. With age, the external environment (availability of sugar and peers) has an increasing influence on behaviour. This suggests that to improve adolescent health, oral health promoters should engage with parents from early childhood and create supportive environments including public policy on sugar availability to encourage uptake of risk-minimising behaviours.
doi:10.1186/s12903-015-0128-1
PMCID: PMC4655499  PMID: 26597279
Dental caries; Oral health; Adolescence; Qualitative; Semi-structured interviews; Influences; Behaviour; Knowledge; Attitudes
3.  Qualitative findings from an exploratory trial of the Healthy Lifestyles Programme (HeLP) and their implications for the process evaluation in the definitive trial 
BMC Public Health  2014;14:578.
Background
Approximately one third of 10-11 year olds in England are now overweight or obese suggesting that population approaches are urgently required. However, despite the increasing number of school-based interventions to prevent obesity, results continue to be inconsistent and it is still unclear what the necessary conditions are that lead to the sustained behaviour change required to affect weight status. The Healthy Lifestyles Programme is a theoretically informed four phase multi-component intervention which seeks to create supportive school and home environments for healthy behaviours.
Methods
A process evaluation has run alongside the exploratory trial of the Healthy Lifestyles Programme to ascertain the feasibility and acceptability of; the trial design (including the trial outcomes) and the HeLP Programme and whether it is able to engage schools, children and their families. Data was collected using interviews with teachers (n = 12) and parents (n = 17) and six focus groups with children (n = 47) and a questionnaire for parents of children in the intervention schools. Interview and focus group data relating to the intervention was analysed using framework analysis.
Results
Four schools and 201 children participated in the exploratory trial. The data showed that the trial design was feasible and acceptable for schools and children. Three themes emerged for the data in relation to the acceptability and feasibility of the HeLP Programme (value, compatibility with the curriculum and enjoyment) and two themes emerged in relation to engagement (‘knowledge and awareness’ and ‘taking messages on board’). The latter could be broken down into 4 subthemes (‘initiating discussion with family and friends’, ‘acceptance of family rules’, ‘increased responsibility’ and ‘the importance of the mode and agent of delivery’). The use of highly inclusive and interactive delivery methods where the children were encouraged to identify with and take ownership of the healthy lifestyle messages were identified as important factors in motivating the children to take the messages home, seek parental support and initiate family lifestyle behaviour change.
Conclusion
The process evaluation of the exploratory trial has not only provided evidence of the feasibility and acceptability of the Programme, it has also allowed an understanding of how HeLP engages schools, children and their families. These findings have informed the process evaluation for the definitive trial.
doi:10.1186/1471-2458-14-578
PMCID: PMC4071326  PMID: 24912844
Feasibility; Acceptability; Exploratory trial; Process evaluation; Engagement; Behaviour change; Supportive contexts
4.  Hawaii’s “7 by 7” for School Health Education: A PowerPoint Presentation on Integrating the National Health Education Standards With Priority Content Areas for Today’s School Health Education in Grades Kindergarten Through 12 
Preventing Chronic Disease  2006;3(2):A63.
School-based health education can help young people develop the knowledge, skills, motivation, and support they need to choose health-enhancing behaviors and resist engaging in behaviors that put them at risk for health and social problems and school failure. The health of school-age youth is significantly associated with their school achievement. However, in the midst of today's increased emphasis on school accountability in the areas of reading, writing, and mathematics, subject areas such as health education tend to receive less prominence in the school curriculum. Recalling their own lackluster school experiences related to health topics, decision makers may not realize that today's skills-based school health curriculum involves a highly interactive and engaging approach to promoting good health and preventing the most serious health problems among youth. Health education is one important component of a coordinated school health program that includes health education, physical education, school health services, nutrition services, school counseling and psychological services, a healthy school environment, school promotion for faculty and staff, and involvement of family and community members. The purpose of this PowerPoint presentation — Healthy Keiki, Healthy Hawaii: Hawaii's "7 by 7" for School Health Education — is to educate health and education decision makers, teachers, parents, and community members on how Hawaii has integrated seven health education standards with seven priority health content areas to create an effective approach to school health education in grades kindergarten through 12. The goal of Hawaii's "7 by 7" curriculum focus is to ensure that all of Hawaii's keiki (children) have well-planned opportunities at school to become fit, healthy, and ready to learn.
PMCID: PMC1563955  PMID: 16539804
5.  Behavioural and weight status outcomes from an exploratory trial of the Healthy Lifestyles Programme (HeLP): a novel school-based obesity prevention programme 
BMJ Open  2012;2(3):e000390.
Objectives
To assess the behavioural and weight status outcomes in English children in a feasibility study of a novel primary school-based obesity prevention programme.
Design
Exploratory cluster randomised controlled trial of the Healthy Lifestyles Programme.
Setting
Four city primary schools (two control and two intervention) in the South West of England.
Participants
202 children aged 9–10 years, of whom 193 and 188 were followed up at 18 and 24 months, respectively. No child was excluded from the study; however, to be eligible, schools were required to have at least one single Year 5 class.
Intervention
Four-phase multicomponent programme using a range of school-based activities including lessons, assemblies, parents' evenings, interactive drama workshops and goal setting to engage and support schools, children and their families in healthy lifestyle behaviours. It runs over the spring and summer term of Year 5 and the autumn term of Year 6.
Primary and secondary outcomes
Weight status outcomes were body mass index, waist circumference and body fat standard deviation scores (SDS) at 18 and 24 months, and behavioural outcomes were physical activity, television (TV) viewing/screen time and food intake at 18 months.
Results
At 18 months of follow-up, intervention children consumed less energy-dense snacks and more healthy snacks; had less ‘negative food markers’, more ‘positive food markers’, lower mean TV/screen time and spent more time doing moderate-vigorous physical activity each day than those in the control schools. Intervention children had lower anthropometric measures at 18 and 24 months than control children, with larger differences at 24 months than at 18 months for nearly all measures.
Conclusions
Results from this exploratory trial show consistent positive changes in favour of the intervention across all targeted behaviours, which, in turn, appear to affect weight status and body shape. A definitive trial is now justified.
Article summary
Article focus
To present behavioural and weight status outcomes from an exploratory cluster randomised controlled trial of a novel school-based obesity prevention programme with English primary school children.
To present sample size estimates required for a definitive trial of the programme based on outcome results, attrition rates and estimates of the intraclass correlations of the outcome measures.
Key messages
The Healthy Lifestyles Programme (HeLP) has been developed using behaviour change theory and extensive stakeholder involvement to engage and support children and their families in healthy lifestyles.
Behavioural and weight status outcomes at 18 and 24 months from this exploratory trial (Phase 3 pilot) show consistency in the direction of effects, all in favour of the intervention, demonstrating ‘proof of concept’.
Results from the exploratory trial have provided sufficient evidence to support the evaluation of HeLP in a full-scale trial.
Strengths and limitations of this study
The HeLP intervention has undergone a systematic development process using research evidence, behavioural theory, stakeholder consultation and piloting. This has enabled the researchers to gain a deeper understanding of the context in which the intervention was to be delivered in order to maximise engagement at all levels. The exploratory trial presented in this paper (Phase 3 pilot) has demonstrated not only that the design of the trial is feasible, with outcome data obtained from 92% of the original cohort at 24 months after transition to secondary school, but also that behavioural and weight status outcome measures at 18 and 24 months show consistency in the direction of effects (although the differences are relatively small), all in favour of the intervention, demonstrating ‘proof of concept’. This shows that a definitive trial of HeLP is both feasible and justified.
The study was conducted in the South West of England, where the population is predominantly white, and although there are areas of deprivation, none of the four schools had ≥25% of children eligible for free school meals (the national average of proportion of children eligible for free school meals). However, the intervention has been developed to allow the flexibility and adaptation to ensure that it is recognising and responding to the local needs of children and families from different socioeconomic and ethnic groups while still maintaining fidelity. Food intake and television (TV) viewing/screen time were self-reported, and although children were asked to sit in their literacy tables so that appropriate support could be provided to each child during completion, the information children are able to provide is limited. We did, however, go to great lengths to ensure that the questionnaires were simple and presented in such a way so as to trigger recall.
doi:10.1136/bmjopen-2011-000390
PMCID: PMC3358612  PMID: 22586282
6.  Evaluation of implementation and effect of primary school based intervention to reduce risk factors for obesity 
BMJ : British Medical Journal  2001;323(7320):1027.
Objectives
To implement a school based health promotion programme aimed at reducing risk factors for obesity and to evaluate the implementation process and its effect on the school.
Design
Data from 10 schools participating in a group randomised controlled crossover trial were pooled and analysed.
Setting
10 primary schools in Leeds.
Participants
634 children (350 boys and 284 girls) aged 7-11 years.
Main outcome measures
Response rates to questionnaires, teachers' evaluation of training and input, success of school action plans, content of school meals, and children's knowledge of healthy living and self reported behaviour.
Results
All 10 schools participated throughout the study. 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals. A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents. 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school. 19 out of 20 teachers attended the training, and all reported satisfaction with the training, resources, and support. Intervention children showed a higher score for knowledge, attitudes, and self reported behaviour for healthy eating and physical activity.
Conclusion
This programme was successfully implemented and produced changes at school level that tackled risk factors for obesity.
What is already known on this topicPrevention of obesity is an increasingly important aspect of health promotionFew trials have investigated school based primary prevention programmes directed at obesityWhat this study addsThe programme was successful in producing school level changes to tackle risk factors for obesityHigh levels of participation indicated support from schools, staff, parents, and pupilsPositive changes were seen in school meals, tuck shops, and playground activities
PMCID: PMC59380  PMID: 11691758
7.  A participatory and capacity-building approach to healthy eating and physical activity – SCIP-school: a 2-year controlled trial 
Background
Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity. A key challenge is the “implementation gap”. Trade-off must be made between expert-driven programmes on the one hand and contextual relevance, flexibility, participation and capacity building on the other. The aim of the Stockholm County Implementation Programme was to improve eating habits, physical activity, self-esteem, and promote a healthy body weight in children aged 6–16 years. We describe the programme, intervention fidelity, impacts and outcomes after two years of intervention.
Methods
Nine out of 18 schools in a middle-class municipality in Sweden agreed to participate whereas the other nine schools served as the comparison group (quasi-experimental study). Tailored action plans were developed by school health teams on the basis of a self-assessment questionnaire called KEY assessing strengths and weaknesses of each school’s health practices and environments. Process evaluation was carried out by the research staff. Impacts at school level were assessed yearly by the KEY. Outcome measures at student level were anthropometry (measured), and health behaviours assessed by a questionnaire, at baseline and after 2 years. All children in grade 2, 4 and 7 were invited to participate (n=1359) of which 59.8% consented. The effect of the intervention on health behaviours, self-esteem, weight status and BMIsds was evaluated by unilevel and multilevel regression analysis adjusted for gender and baseline values.
Results
Programme fidelity was high demonstrating feasibility, but fidelity to school action plans was only 48% after two years. Positive and significant (p<.05) impacts were noted in school health practices and environments after 2 years. At student level no significant intervention effects were seen for the main outcomes.
Conclusions
School staff has the capacity to create their own solutions and make changes at school level on the basis of self-assessment and facilitation by external agents. However these changes were challenging to sustain over time and had little impact on student behaviours or weight status. Better student outcomes could probably be attained by a more focused and evidence-based approach with stepwise implementation of action plans.
doi:10.1186/1479-5868-9-145
PMCID: PMC3545832  PMID: 23245473
Children; Eating habits; Exercise; Fidelity; Health promotion; Obesity prevention; Process evaluation; Quasi-experimental study; Self-esteem
8.  Childhood obesity management shifting from health care system to school system: intervention study of school-based weight management programme 
BMC Public Health  2014;14:1128.
Background
Home and school environments conducive for unhealthy eating and physical inactivity are precursors of obesity. The aim of this study is evaluation of the effectiveness of a multi-component school-based weight management programme for overweight and obese primary school children via a home-school joint venture.
Methods
This study made use of variety of behavioural modification strategies integrating into the Health Promoting School approach to promote healthy lifestyles. The participants were overweight and obese students aged between 8 and 12 from six participating schools. The interventions involved students attending ten 75 minutes after-school sessions and one 3-hour week-end session of practical interactive and fun activities on healthy eating and exercise, and meal plan together with parents and printed tailor-made management advices. Parents received an introductory seminar with 2 sets of specially designed exercise for their overweight children. The tools to measure bodyweight and fat percentage and standing height were bio-impedance body fat scale and a portable stadiometer. Self-administered questionnaire was used to measure knowledge, attitudes and behaviours. McNemar test was utilized to compare the proportions of behaviour changes within the same group to assess for the trends of changes. BMI z-score and body fat percentage of intervention participants at baseline, 4 month and 8 month were compared pair-wisely using tests of within subject contrasts in repeated measures ANOVA to assess for programme sustainability.
Results
Those students in the intervention group reduced their BMI z-score (-0.21, 95% CI -0.34 to -0.07, P = 0.003) and body fat (-2.67%, 95% CI -5.12 to -0.22, P = 0.033) compared to wait list control group with statistical significant, and the intervention group also had a significant reduction in BMI z-score (-0.06, 95% CI -0.11, -0.007, P = 0.028) and body fat (-1.71%, 95% CI, -3.44 to 0.02, P = 0.052) after a 4 month maintenance period. Improvement of dietary habits and positive attitudes towards exercise were observed among the intervention group.
Conclusion
School based weight management programme integrated into a Health Promoting School approach with improved school policies and environment in supporting individual skills of obese students and their parents appears to be a promising practice for sustaining weight control.
Trial registration
ISRCTN58795797.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1128) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1128
PMCID: PMC4289207  PMID: 25363153
Childhood obesity; School based programme; Intervention
9.  Engaging Communities to Develop and Sustain Comprehensive Wellness Policies: Louisiana’s Schools Putting Prevention to Work 
Background
Tobacco use, obesity, and physical inactivity among Louisiana’s youth pose a serious public health problem. Given the potential of school environments to affect student well-being, the Louisiana Tobacco Control Program developed and tested a pilot program, Schools Putting Prevention to Work. The objective was to assist school districts in developing a comprehensive school wellness policy and engaging their school community to generate environments that support healthful choices and behaviors.
Community Context
The pilot was implemented in 27 school districts, reaching an estimated 325,000 people across the state. Demographics of participating students were similar to all Louisiana’s public school students.
Methods
A school wellness project state team advised project development. A subgroup that included contractors and partners implemented and modified the pilot. Sites were selected though an application process. Site representatives received trainings, technical assistance, and funding to organize school-based support-building activities and coordinate a school health advisory council to develop policy and sustain healthy school environments. Project sites reported progress monthly; evaluation included data from sites and project administrators.
Outcome
Twenty-five comprehensive school wellness policies (covering 100% tobacco-free schools and daily physical activity and healthier cafeteria items) were approved by school boards. Environmental changes such as physical activity breaks, healthier vending options, and tobacco-free campuses were adopted.
Interpretation
This pilot demonstrated a successful approach to achieving policy and environmental change. The state team engaged and guided school districts to motivate students, parents, faculty/staff/administration, and businesses to establish and maintain opportunities to improve lifestyle health.
doi:10.5888/pcd11.130149
PMCID: PMC3945076  PMID: 24602588
10.  Headteachers’ prior beliefs on child health and their engagement in school based health interventions: a qualitative study 
BMC Research Notes  2015;8:161.
Background
Schools play an important role in promoting the health of children. However, little consideration is often given to the influence that headteachers’ and school staff’s prior beliefs have on the implementation of public health interventions. This study examined primary school headteachers’ and school health co-ordinators’ views regarding child health in order to provide greater insights on the school’s perspective for those designing future school-based health interventions.
Methods
A qualitative study was conducted using 19 semi-structured interviews with headteachers, deputy headteachers and school health co-ordinators in the primary school setting. All transcripts were analysed using thematic analysis.
Results
Whilst many participants in this study believed good health was vital for learning, wide variance was evident regarding the perceived health of school pupils and the magnitude of responsibility schools should take in addressing child health behaviours. Although staff in this study acknowledged the importance of their role, many believed the responsibility placed upon schools for health promotion was becoming too much; suggesting health interventions need to better integrate school, parental and societal components. With mental health highlighted as an increasing priority in many schools, incorporating wellbeing outcomes into future school based health interventions is advocated to ensure a more holistic understanding of child health is gained.
Conclusion
Understanding the health beliefs of school staff when designing interventions is crucial as there appears to be a greater likelihood of interventions being successfully adopted if staff perceive a health issue as important among their pupils. An increased dependability on schools for addressing health was expressed by headteachers in this study, highlighting a need for better understanding of parental, child and key stakeholder perspectives on responsibility for child health. Without this understanding, there is potential for certain child health issues to be ignored.
doi:10.1186/s13104-015-1091-2
PMCID: PMC4414301  PMID: 25925554
Primary school; Qualitative; Headteacher; Children; Health; Beliefs
11.  Children’s participation in school: a cross-sectional study of the relationship between school environments, participation and health and well-being outcomes 
BMC Public Health  2014;14:964.
Background
Schools are a key setting for health promotion and improvement activities and the psycho-social environment of the school is an important dimension for promoting the health and well-being of children. The development of Health Promoting Schools (HPS) draws on the settings-based approach to health promotion and includes child participation as one of its basic values. This paper investigates the relationships between child participation, the school environment and child outcomes.
Methods
Study participants were recruited from nine primary schools, three of which were designated as Health Promoting Schools (HPS). Each HPS was matched with two non-HPS (NHPS) with similar characteristics. Two hundred and thirty-one pupils in the 4th-6th class groups completed self-report questionnaires to document their perspectives on the school socio-ecological environment, how they take part in school life, school processes and their health and well-being.
Results
School participation was measured with four scales: participation in school decisions and rules, school activities, school events and positive perception of school participation. The differences in the reported mean score for three of the four scales were marginal and not statistically significant. However, the mean score for reported positive perception of school participation was significantly lower (χ2 = 5.13, df =1, p < 0.05) among pupils in HPS (mean = 26.03; SD 3.37) compared to NHPS (mean = 26.30; SD 3.36). Participation in school decisions and rules (OR 1.22, 95% CI 1.12-1.33), participating in school activities (OR 1.20, 95% CI 1.10-1.31), participating in school events (OR 1.19, 95% CI 1.10-1.29) and reported positive perception of school participation (OR 1.26, 95% CI 1.15-1.39) were all positively associated with health and well-being outcomes for all pupils. Logistic regression analyses indicated positive associations between school participation and school socio-ecological environment.
Conclusions
These findings suggest that school participation is important for children in schools and is relevant for improved school environment, relationships and positive health and well-being outcomes. The positive associations between school participation and school socio-ecological environment and health and well-being outcomes suggests that pupil health and well-being and school relationships could be improved or sustained by providing or supporting an environment that encourages pupil participation in school life.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-964) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-964
PMCID: PMC4177162  PMID: 25230941
Children’s participation; School socio-ecological environment; Health and well-being outcomes; Health promoting schools; Ireland
12.  State but not District Nutrition Policies Are Associated with Less Junk Food in Vending Machines and School Stores in US Public Schools 
Background
Policy that targets the school food environment has been advanced as one way to increase the availability of healthy food at schools and healthy food choice by students. Although both state- and district-level policy initiatives have focused on school nutrition standards, it remains to be seen whether these policies translate into healthy food practices at the school level, where student behavior will be impacted.
Objective
To examine whether state- and district-level nutrition policies addressing junk food in school vending machines and school stores were associated with less junk food in school vending machines and school stores. Junk food was defined as foods and beverages with low nutrient density that provide calories primarily through fats and added sugars.
Design
A cross-sectional study design was used to assess self-report data collected by computer-assisted telephone interviews or self-administered mail questionnaires from state-, district-, and school-level respondents participating in the School Health Policies and Programs Study 2006. The School Health Policies and Programs Study, administered every 6 years since 1994 by the Centers for Disease Control and Prevention, is considered the largest, most comprehensive assessment of school health policies and programs in the United States.
Subjects/setting
A nationally representative sample (n = 563) of public elementary, middle, and high schools was studied.
Statistical analysis
Logistic regression adjusted for school characteristics, sampling weights, and clustering was used to analyze data. Policies were assessed for strength (required, recommended, neither required nor recommended prohibiting junk food) and whether strength was similar for school vending machines and school stores.
Results
School vending machines and school stores were more prevalent in high schools (93%) than middle (84%) and elementary (30%) schools. For state policies, elementary schools that required prohibiting junk food in school vending machines and school stores offered less junk food than elementary schools that neither required nor recommended prohibiting junk food (13% vs 37%; P = 0.006). Middle schools that required prohibiting junk food in vending machines and school stores offered less junk food than middle schools that recommended prohibiting junk food (71% vs 87%; P = 0.07). Similar associations were not evident for district-level polices or high schools.
Conclusions
Policy may be an effective tool to decrease junk food in schools, particularly in elementary and middle schools.
doi:10.1016/j.jada.2010.04.008
PMCID: PMC3270690  PMID: 20630161
13.  Sustainable practice change: Professionals' experiences with a multisectoral child health promotion programme in Sweden 
Background
New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.
Methods
All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n = 23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for programme sustainability.
Results
The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for programme sustainability.
Conclusions
These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a programme requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.
doi:10.1186/1472-6963-11-61
PMCID: PMC3077331  PMID: 21426583
14.  The BBaRTS Healthy Teeth Behaviour Change Programme for preventing dental caries in primary school children: study protocol for a cluster randomised controlled trial 
Trials  2016;17:103.
Background
Oral health behaviours such as establishing twice-daily toothbrushing and sugar control intake need parental self-efficacy (PSE) to prevent the development of childhood dental caries. A previous study has shown that behaviour change techniques (BCTs) delivered via a storybook can improve parental self-efficacy to undertake twice-daily toothbrushing. Objective: to determine whether an intervention (BBaRTS, Bedtime Brush and Read Together to Sleep), designed to increase PSE; delivered through storybooks with embedded BCTs, parenting skills and oral health messages, can improve child oral health compared to (1) an exactly similar intervention containing no behaviour change techniques, and (2) the BBaRTS intervention supplemented with home supply of fluoride toothpaste and supervised toothbrushing on schooldays.
Methods/Design
A 2-year, three-arm, multicentre, cluster randomised controlled trial. Participants: children (estimated 2000–2600) aged 5–7 years and their families from 60 UK primary schools. Intervention: Test group 1: a series of eight children’s storybooks developed by a psychologist, public health dentist, science educator, children’s author and illustrators, with guidance from the Department for Education (England). The books feature animal characters and contain embedded dental health messages, parenting skills and BCTs to promote good oral health routines focused on controlling sugar intake and toothbrushing, as well as reading at bedtime. Books are given out over 2 years. Test group 2: as Test group 1 plus home supplies of fluoride toothpaste (1000 ppmF), and daily supervised toothbrushing in school on schooldays. Active Control group: series of eight books with exactly the same stories, characters and illustrations, but without BCTs, dental health messages or parenting skills. Annual child dental examinations and parental questionnaires will be undertaken. A sub-set of participants will be invited to join an embedded study of the child’s diet and salivary microbiota composition. Primary outcome measure: dental caries experience in permanent teeth at age 7–8 years.
Discussion
A multi-disciplinary team was established to develop the BBaRTS Children’s Healthy Teeth Programme. The books were developed in partnership with the Department for Education (England), informed by a series of focus groups with children, teachers and parents.
Trial registration
ISRCTN21461006 (date of registration 23 September 2015).
doi:10.1186/s13063-016-1226-3
PMCID: PMC4761186  PMID: 26897029
Dental caries; Behaviour change; Storybooks; Fluoride toothpaste; Free sugars; Microbiota
15.  “HealthKick”: Formative assessment of the health environment in low-resource primary schools in the Western Cape Province of South Africa 
BMC Public Health  2012;12:794.
Background
This study evaluated the primary school environment in terms of being conducive to good nutrition practices, sufficient physical activity and prevention of nicotine use, with the view of planning a school-based health intervention.
Methods
A sample of 100 urban and rural disadvantaged schools was randomly selected from two education districts of the Western Cape Education Department, South Africa. A situation analysis, which comprised an interview with the school principal and completion of an observation schedule of the school environment, was done at all schools.
Results
Schools, on average, had 560 learners and 16 educators. Principals perceived the top health priorities for learners to be an unhealthy diet (50%) and to far lesser degree, lack of physical activity (24%) and underweight (16%). They cited lack of physical activity (33%) and non-communicable diseases (NCDs; 24%) as the main health priorities for educators, while substance abuse (66%) and tobacco use (31%) were prioritised for parents. Main barriers to health promotion programmes included lack of financial resources and too little time in the time table. The most common items sold at the school tuck shops were crisps (100%), and then sweets (96%), while vendors mainly sold sweets (92%), crisps (89%), and ice lollies (38%). Very few schools (8%) had policies governing the type of food items sold at school. Twenty-six of the 100 schools that were visited had vegetable gardens. All schools reported having physical activity and physical education in their time tables, however, not all of them offered this activity outside the class room. Extramural sport offered at schools mainly included athletics, netball, and rugby, with cricket and soccer being offered less frequently.
Conclusion
The formative findings of this study contribute to the knowledge of key environmental and policy determinants that may play a role in the health behaviour of learners, their parents and their educators. Evidently, these show that school environments are not always conducive to healthy lifestyles. To address the identified determinants relating to learners it is necessary to intervene on the various levels of influence, i.e. parents, educators, and the support systems for the school environment including the curriculum, food available at school, resources for physical activity as well as appropriate policies in this regard.
doi:10.1186/1471-2458-12-794
PMCID: PMC3503731  PMID: 22985326
Non-communicable diseases; School health environment; Nutrition; Physical activity
16.  Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools 
BMC Public Health  2015;15:946.
Background
Systematic reviews have highlighted that school-based diet and physical activity (PA) interventions have had limited effects. This study used qualitative methods to examine how the effectiveness of future primary (elementary) school diet and PA interventions could be improved.
Methods
Data are from the Active For Life Year 5 (AFLY5) study, which was a cluster randomised trial conducted in 60 UK primary schools. Year 5 (8–9 years of age) pupils in the 30 intervention schools received a 12-month intervention. At the end of the intervention period, interviews were conducted with: 28 Year 5 teachers (including 8 teachers from control schools); 10 Headteachers (6 control); 31 parents (15 control). Focus groups were conducted with 70 year 5 pupils (34 control). Topics included how the AFLY5 intervention could have been improved and how school-based diet and PA interventions should optimally be delivered. All interviews and focus groups were transcribed and thematically analysed across participant groups.
Results
Analysis yielded four themes.
Child engagement: Data suggested that programme success is likely to be enhanced if children feel that they have a sense of autonomy over their own behaviour and if the activities are practical.
School: Finding a project champion within the school would enhance intervention effectiveness. Embedding diet and physical activity content across the curriculum and encouraging teachers to role model good diet and physical activity behaviours were seen as important.
Parents and community: Encouraging parents and community members into the school was deemed likely to enhance the connection between schools, families and communities, and “create a buzz” that was likely to enhance behaviour change.
Government/Policy: Data suggested that there was a need to adequately resource health promotion activity in schools and to increase the infrastructure to facilitate diet and physical activity knowledge and practice.
Discussion and Conclusions
Future primary school diet and PA programmes should find ways to increase child engagement in the programme content, identify programme champions, encourage teachers to work as role models, engage parents and embed diet and PA behaviour change across the curriculum. However, this will require adequate funding and cost-effectiveness will need to be established.
Trial registration
ISRCTN50133740
doi:10.1186/s12889-015-2293-1
PMCID: PMC4580292  PMID: 26399328
Diet; Physical activity; RCT; Process evaluation; Schools; Children
17.  The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation 
Background
Studies in resource-limited settings have shown that there are constraints to the use of teachers, peers or health professionals to deliver school health promotion interventions. School health programmes delivered by trained lay health counsellors could offer a cost-effective alternative. This paper presents a case study of a multi-component school health promotion intervention in India that was delivered by lay school health counsellors, who possessed neither formal educational nor health provider qualifications.
Methods
The intervention was based on the WHO’s Health Promoting Schools framework, and included health screening camps; an anonymous letter box for student questions and complaints; classroom-based life skills training; and, individual psycho-social and academic counselling for students. The intervention was delivered by a lay school health counsellor who had attained a minimum of a high school education. The counsellor was trained over four weeks and received structured supervision from health professionals working for the implementing NGO. The evaluation design was a mixed methods case study. Quantitative process indicators were collected to assess the extent to which the programme was delivered as planned (feasibility), the uptake of services (acceptability), and the number of students who received corrective health treatment (evidence of impact). Semi-structured interviews were conducted over two years with 108 stakeholders, and were analysed to identify barriers and facilitators for the programme (feasibility), evaluate acceptability, and gather evidence of positive or negative effects of the programme.
Results
Feasibility was established by the high reported coverage of all the targeted activities by the school health counsellor. Acceptability was indicated by a growing number of submissions to the students’ anonymous letter-box; more students self-referring for counselling services over time; and, the perceived need for the programme, as expressed by principals, parents and students. A minority of teachers complained that there was inadequate information sharing about the programme and mentioned reservations about the capacities of the lay health counsellor. Preliminary evidence of the positive effects of the programme included the correction of vision problems detected in health screening camps, and qualitative evidence of changes in health-related knowledge and behaviour of students.
Conclusion
A task-shifting approach of delegating school health promotion activities to lay school health counsellors rather than education or health professionals shows promise of effectiveness as a scalable model for promoting the health and well being of school based adolescents in resource constrained settings.
doi:10.1186/1472-6963-12-127
PMCID: PMC3461450  PMID: 22630607
18.  Do schools differ in suicide risk? the influence of school and neighbourhood on attempted suicide, suicidal ideation and self-harm among secondary school pupils 
BMC Public Health  2011;11:874.
Background
Rates of suicide and poor mental health are high in environments (neighbourhoods and institutions) where individuals have only weak social ties, feel socially disconnected and experience anomie - a mismatch between individual and community norms and values. Young people spend much of their time within the school environment, but the influence of school context (school connectedness, ethos and contextual factors such as school size or denomination) on suicide-risk is understudied. Our aim is to explore if school context is associated with rates of attempted suicide and suicide-risk at age 15 and self-harm at age 19, adjusting for confounders.
Methods
A longitudinal school-based survey of 1698 young people surveyed when aged 11, (primary school), 15 (secondary school) and in early adulthood (age 19). Participants provided data about attempted suicide and suicide-risk at age 15 and deliberate self-harm at 19. In addition, data were collected about mental health at age 11, social background (gender, religion, etc.), and at age 15, perception of local area (e.g. neighbourhood cohesion, safety/civility and facilities), school connectedness (school engagement, involvement, etc.) and school context (size, denomination, etc.). A dummy variable was created indicating a religious 'mismatch', where pupils held a different faith from their school denomination. Data were analysed using multilevel logistic regression.
Results
After adjustment for confounders, pupils attempted suicide, suicide-risk and self-harm were all more likely among pupils with low school engagement (15-18% increase in odds for each SD change in engagement). While holding Catholic religious beliefs was protective, attending a Catholic school was a risk factor for suicidal behaviours. This pattern was explained by religious 'mismatch': pupils of a different religion from their school were approximately 2-4 times more likely to attempt suicide, be a suicide-risk or self-harm.
Conclusions
With several caveats, we found support for the importance of school context for suicidality and self-harm. School policies promoting school connectedness are uncontroversial. Devising a policy to reduce risks to pupils holding a different faith from that of their school may be more problematic.
doi:10.1186/1471-2458-11-874
PMCID: PMC3280202  PMID: 22093491
19.  Obesity prevention and the Health promoting Schools framework: essential components and barriers to success 
Background
Obesity is an important public health issue. Finding ways to increase physical activity and improve nutrition, particularly in children, is a clear priority. Our Cochrane review of the World Health Organization’s Health Promoting Schools (HPS) framework found this approach improved students’ physical activity and fitness, and increased fruit and vegetable intake. However, there was considerable heterogeneity in reported impacts. This paper synthesises process evaluation data from these studies to identify factors that might explain this variability.
Methods
We searched 20 health, education and social-science databases, and trials registries and relevant websites in 2011 and 2013. No language or date restrictions were applied. We included cluster randomised controlled trials. Participants were school students aged 4-18 years. Studies were included if they: took an HPS approach (targeting curriculum, environment and family/community); focused on physical activity and/or nutrition; and presented process evaluation data. A framework approach was used to facilitate thematic analysis and synthesis of process data.
Results
Twenty-six studies met the inclusion criteria. Most were conducted in America or Europe, with children aged 12 years or younger.
Although interventions were acceptable to students and teachers, fidelity varied considerably across trials. Involving families, while an intrinsic element of the HPS approach, was viewed as highly challenging. Several themes emerged regarding which elements of interventions were critical for success: tailoring programmes to individual schools’ needs; aligning interventions with schools’ core aims; working with teachers to develop programmes; and providing on-going training and support. An emphasis on academic subjects and lack of institutional support were barriers to implementation.
Conclusions
Stronger alliances between health and education appear essential to intervention success. Researchers must work with schools to develop and implement interventions, and to evaluate their impact on both health and educational outcomes as this may be a key determinant of scalability. If family engagement is attempted, better ways to achieve this must be developed and evaluated. Further evaluations of interventions to promote physical activity and nutrition during adolescence are needed. Finally, process evaluations must move beyond simple measures of acceptability/fidelity to include detailed contextual information to illuminate exactly what works, for whom, in what contexts and why.
doi:10.1186/s12966-015-0167-7
PMCID: PMC4330926  PMID: 25885800
Children; Adolescents; Interventions; Schools; Physical activity; Healthy eating; Process evaluation; Health promoting Schools
20.  Community led active schools programme (CLASP) exploring the implementation of health interventions in primary schools: headteachers’ perspectives 
BMC Public Health  2015;15:238.
Background
Schools are repeatedly utilised as a key setting for health interventions. However, the translation of effective research findings to the school setting can be problematic. In order to improve effective translation of future interventions, it is imperative key challenges and facilitators of implementing health interventions be understood from a school’s perspective.
Methods
Nineteen semi-structured interviews were conducted in primary schools (headteachers n = 16, deputy headteacher n = 1, healthy school co-ordinator n = 2). Interviews were transcribed verbatim and analysed using thematic analysis.
Results
The main challenges for schools in implementing health interventions were; government-led academic priorities, initiative overload, low autonomy for schools, lack of staff support, lack of facilities and resources, litigation risk and parental engagement. Recommendations to increase the application of interventions into the school setting included; better planning and organisation, greater collaboration with schools and external partners and elements addressing sustainability. Child-centred and cross-curricular approaches, inclusive whole school approaches and assurances to be supportive of the school ethos were also favoured for consideration.
Conclusions
This work explores schools’ perspectives regarding the implementation of health interventions and utilises these thoughts to create guidelines for developing future school-based interventions. Recommendations include the need to account for variability between school environments, staff and pupils. Interventions with an element of adaptability were preferred over the delivery of blanket fixed interventions. Involving schools in the developmental stage would add useful insights to ensure the interventions can be tailored to best suit each individual schools’ needs and improve implementation.
doi:10.1186/s12889-015-1557-0
PMCID: PMC4381418  PMID: 25886398
Qualitative; Interviews; Headteachers; Health interventions; Physical activity; Primary school; Children
21.  The Long-Term Effects of a Peer-Led Sex Education Programme (RIPPLE): A Cluster Randomised Trial in Schools in England 
PLoS Medicine  2008;5(11):e224.
Background
Peer-led sex education is widely believed to be an effective approach to reducing unsafe sex among young people, but reliable evidence from long-term studies is lacking. To assess the effectiveness of one form of school-based peer-led sex education in reducing unintended teenage pregnancy, we did a cluster (school) randomised trial with 7 y of follow-up.
Methods and Findings
Twenty-seven representative schools in England, with over 9,000 pupils aged 13–14 y at baseline, took part in the trial. Schools were randomised to either peer-led sex education (intervention) or to continue their usual teacher-led sex education (control). Peer educators, aged 16–17 y, were trained to deliver three 1-h classroom sessions of sex education to 13- to 14-y-old pupils from the same schools. The sessions used participatory learning methods designed to improve the younger pupils' skills in sexual communication and condom use and their knowledge about pregnancy, sexually transmitted infections (STIs), contraception, and local sexual health services. Main outcome measures were abortion and live births by age 20 y, determined by anonymised linkage of girls to routine (statutory) data. Assessment of these outcomes was blind to sex education allocation. The proportion of girls who had one or more abortions before age 20 y was the same in each arm (intervention, 5.0% [95% confidence interval (CI) 4.0%–6.3%]; control, 5.0% [95% CI 4.0%–6.4%]). The odds ratio (OR) adjusted for randomisation strata was 1.07 (95% CI 0.80–1.42, p = 0.64, intervention versus control). The proportion of girls with one or more live births by 20.5 y was 7.5% (95% CI 5.9%–9.6%) in the intervention arm and 10.6% (95% CI 6.8%–16.1%) in the control arm, adjusted OR 0.77 (0.51–1.15). Fewer girls in the peer-led arm self-reported a pregnancy by age 18 y (7.2% intervention versus 11.2% control, adjusted OR 0.62 [95% CI 0.42–0.91], weighted for non-response; response rate 61% intervention, 45% control). There were no significant differences for girls or boys in self-reported unprotected first sex, regretted or pressured sex, quality of current sexual relationship, diagnosed sexually transmitted diseases, or ability to identify local sexual health services.
Conclusion
Compared with conventional school sex education at age 13–14 y, this form of peer-led sex education was not associated with change in teenage abortions, but may have led to fewer teenage births and was popular with pupils. It merits consideration within broader teenage pregnancy prevention strategies.
Trial registration:
ISRCTN (ISRCTN94255362).
Judith Stephenson and colleagues report on a cluster randomized trial in London of school-based peer-led sex education and whether it reduced unintended teenage pregnancy.
Editors' Summary
Background.
Teenage pregnancies are fraught with problems. Children born to teenage mothers are often underweight, which can affect their long-term health; young mothers have a high risk of poor mental health after the birth; and teenage parents and their children are at increased risk of living in poverty. Little wonder, then, that faced with one of the highest teenage pregnancy rates in Western Europe, the Department of Health in England launched a national Teenage Pregnancy Strategy in 2000 to reduce teenage pregnancies. The main goal of the strategy is to halve the 1998 under-18 pregnancy rate—there were 46.6 pregnancies for every 1,000 young women in this age group in that year—by 2010. Approaches recommended in the strategy to achieve this goal include the provision of effective sexual health advice services for young people, active engagement of health, social, youth support, and other services in the reduction of teenage pregnancies, and the improvement of sex and relationships education (SRE).
Why Was This Study Done?
Although the annual under-18 pregnancy rate in England is falling, it is still very high, and it is extremely unlikely that the main goal of the Teenage Pregnancy Strategy will be achieved. Experts are, therefore, looking for better ways to reduce both teenage pregnancy rates and the high rates of sexual transmitted diseases among teenagers. Many believe that peer-led SRE—the teaching (sharing) of sexual health information, values, and behaviours by people of a similar age or status group—might be a good approach to try. Peers, they suggest, might convey information about sexual health and relationships better than teachers. However, little is known about the long-term effectiveness of peer-led SRE. In this randomized cluster trial, the researchers compare the effects of a peer-led SRE program and teacher-led sex education given to13- to 14-y-old pupils on abortion and live birth numbers among young women up to age 20 y. In a cluster randomized trial, participants are randomly assigned to the interventions being compared in “clusters”; in this trial, each “cluster” is a school.
What Did the Researchers Do and Find?
Twenty-seven schools in England (about 9,000 13- to 14-y-old pupils) participated in the RIPPLE (Randomized Intervention of PuPil-Led sex Education) trial. Each school was randomly assigned to peer-led SRE (the intervention arm) or to existing teacher-led SRE (the control arm). For peer-led SRE, trained 16- to 17-y-old peer educators gave three 1-h SRE sessions to the younger pupils in their schools. These sessions included practice with condoms, role play to improve sexual negotiating skills, and exercises to improve knowledge about sexual health. The researchers then used routine data on abortions and live births to find out how many female study participants had had an unintended pregnancy before the age of 20 y. One in 20 girls in both study arms had had one or more abortions. Slightly more girls in the control arm than in the intervention arm had had live births, but the difference was small and might have occurred by chance. However, significantly more girls in the intervention arm (11.2%) self-reported a pregnancy by age 18 than in the intervention arm (7.2%). There were no differences between the two arms for girls or boys in any other aspect of sexual health, including sexually transmitted diseases.
What Do These Findings Mean?
These findings indicate that the peer-led SRE program used in this trial had no effect on the number of teenage abortions but may have led to slightly fewer live births among the young women in the study. This particular peer-led SRE program was very short so a more extended program might have had a more marked effect on teenage pregnancy rates; this possibility needs to be tested, particularly since the pupils preferred peer-led SRE to teacher-led SRE. Even though peer-led SRE requires more resources than teacher-led SRE, this form of SRE should probably still be considered as part of a broad teenage prevention strategy, suggest the researchers. But, they warn, their findings should also “temper high expectations about the long-term impact of peer-led approaches” on young people's sexual health.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050224.
This study is further discussed in a PLoS Medicine Perspective by David Ross
Every Child Matters, a Web site produced by the UK government, includes information on teenage pregnancy, the Teenage Pregnancy Strategy, and teenage pregnancy statistics in England
Directgov, an official government Web site for UK citizens, provides advice for parents on talking to children about sex and teenage pregnancyand advice for young people on sexual health and preventing pregnancy
Teachernet, a UK source of online publications for schools, also provides information for parents about sex and relationships education and the UK government's current guidance on SRE in schools
Avert, an international AIDS charity, also provides a fact sheet on sex education
The Sex Education Forum in the UK is the national authority on Sex and Relationships Education
doi:10.1371/journal.pmed.0050224
PMCID: PMC2586352  PMID: 19067478
22.  Perceptions of Middle School Educators in Hawai‘i about School-based Gardening and Child Health 
Hawaii Medical Journal  2011;70(7 suppl 1):11-15.
Background
Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health.
Methods
Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai‘i were conducted. Data were analyzed using a grounded theory approach.
Results
Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health.
Conclusions
In order to be effective at obesity prevention, school-based gardening programs in Hawai‘i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.
PMCID: PMC3158450  PMID: 21886287
23.  The Lime Tree School endeavour: healthy body, brain and heart 
Key messages
Partnership working helps to realise health, educational, social and organisational gain, eliminating boundaries and bringing about better outcomes for children and young people.
Efforts should always be focused on the pupil, the resident and the patient. Care or services should be tailor-made for individuals.
Leadership within organisations and communities is an essential ingredient in partnership endeavours.
Why this matters to me
I have always been concerned that organisational change within the NHS has done more to exaggerate the differences between and within organisations than celebrate the connections. I am often struck by the rationale that prevents people working together which is linked to how organisations are structured and how roles are defined (or restricted) by directorates rather than objectives. So the question is this, ‘Is it time to look outside of our organisational constructs to achieve a set of shared objectives using the resources of many?’
The provision of the school nursing service has always been part of our ‘regular’ commissioned schedule. It is a service that supports the personal, social and health element of the educational curriculum. So when the opportunity came to do more to break down the barriers between health and education and join with our partners to create the opportunity to deliver on a set of shared objectives, we grabbed it with both hands. Here was the chance to truly embed health into the curriculum and offer the children in our community the best possible start on their life journey. It was something that the Office of the Schools' Adjudicator obviously recognised too because they awarded the contract to our partnership in the face of stiff competition from an academy. Lime Tree Primary School has the best of all worlds – it is at the heart of its local community, promoting sustainability, wellbeing, lifelong learning and an active lifestyle, supported by 21st century facilities and technology. As the school nears the half-way mark in its first year of operation, we applaud the varied activities they have already experienced, from yoga to gardening on the rooftop allotment and even an Extreme Reading Competition, which saw the joint winners reading a book while doing a snowplough down a mountain and another one perched on an airport carousel. We don't know yet what 2013 will bring in our joint venture, but we are sure of one thing, it will be rewarding and we will be extremely proud of our involvement in this marvellous collaboration which aims to meet our shared objectives.
Imagine what fun pupils would have at a school where the head dresses up as Dennis the Menace for World Book Day? And equally beneficial to the school, where parents can achieve a sustainable win–win by donating unwanted clothing, which is then sold to recyclers to boost school funds? These are the values that sustain Lime Tree Primary, Kingston's newest school which opened its doors in September 2012. Central to the school's ethos is the unique partnership between health and education that has transformed this fledgling primary school into a real community asset. The problem was a real one facing many local authorities today: a rising birth rate and too few classroom places; a new build seemed the obvious solution – and a real opportunity. Local children, their families, residents and professionals were interviewed and their ideas translated into proposals for the new school. A magical learning environment for local youngsters was created, embodied by the school motto, which recognises that a healthy body sustains better learning, and better learning leads to enhanced health benefits. The school lives and breathes ‘Healthy Body, Brain and Heart’ and transfers this into all its daily activities. And what of the future? There is no doubt that this type of initiative could be adopted in other parts of the new NHS. Wouldn't it be marvellous if other examples of like collaboration could help us jointly tackle the challenges of modern-day living?
PMCID: PMC3960650  PMID: 25949696
community; education; healthcare; partnership; public health
24.  The Lime Tree School endeavour: healthy body, brain and heart 
London Journal of Primary Care  2013;5(1):111-113.
Key messages
Partnership working helps to realise health, educational, social and organisational gain, eliminating boundaries and bringing about better outcomes for children and young people.
Efforts should always be focused on the pupil, the resident and the patient. Care or services should be tailor-made for individuals.
Leadership within organisations and communities is an essential ingredient in partnership endeavours.
Why this matters to me
I have always been concerned that organisational change within the NHS has done more to exaggerate the differences between and within organisations than celebrate the connections. I am often struck by the rationale that prevents people working together which is linked to how organisations are structured and how roles are defined (or restricted) by directorates rather than objectives. So the question is this, ‘Is it time to look outside of our organisational constructs to achieve a set of shared objectives using the resources of many?’
The provision of the school nursing service has always been part of our ‘regular’ commissioned schedule. It is a service that supports the personal, social and health element of the educational curriculum. So when the opportunity came to do more to break down the barriers between health and education and join with our partners to create the opportunity to deliver on a set of shared objectives, we grabbed it with both hands. Here was the chance to truly embed health into the curriculum and offer the children in our community the best possible start on their life journey. It was something that the Office of the Schools' Adjudicator obviously recognised too because they awarded the contract to our partnership in the face of stiff competition from an academy. Lime Tree Primary School has the best of all worlds – it is at the heart of its local community, promoting sustainability, wellbeing, lifelong learning and an active lifestyle, supported by 21st century facilities and technology. As the school nears the half-way mark in its first year of operation, we applaud the varied activities they have already experienced, from yoga to gardening on the rooftop allotment and even an Extreme Reading Competition, which saw the joint winners reading a book while doing a snowplough down a mountain and another one perched on an airport carousel. We don't know yet what 2013 will bring in our joint venture, but we are sure of one thing, it will be rewarding and we will be extremely proud of our involvement in this marvellous collaboration which aims to meet our shared objectives.
Imagine what fun pupils would have at a school where the head dresses up as Dennis the Menace for World Book Day? And equally beneficial to the school, where parents can achieve a sustainable win–win by donating unwanted clothing, which is then sold to recyclers to boost school funds? These are the values that sustain Lime Tree Primary, Kingston's newest school which opened its doors in September 2012. Central to the school's ethos is the unique partnership between health and education that has transformed this fledgling primary school into a real community asset. The problem was a real one facing many local authorities today: a rising birth rate and too few classroom places; a new build seemed the obvious solution – and a real opportunity. Local children, their families, residents and professionals were interviewed and their ideas translated into proposals for the new school. A magical learning environment for local youngsters was created, embodied by the school motto, which recognises that a healthy body sustains better learning, and better learning leads to enhanced health benefits. The school lives and breathes ‘Healthy Body, Brain and Heart’ and transfers this into all its daily activities. And what of the future? There is no doubt that this type of initiative could be adopted in other parts of the new NHS. Wouldn't it be marvellous if other examples of like collaboration could help us jointly tackle the challenges of modern-day living?
PMCID: PMC4413711  PMID: 25949681
community; education; healthcare; partnership; public health
25.  The School Health Index as an Impetus for Change1  
Preventing Chronic Disease  2004;2(1):A19.
Background
The increase in childhood obesity and prevalence of chronic disease risk factors demonstrate the importance of creating healthy school environments. As part of the Border Health Strategic Initiative, the School Health Index was implemented in public schools in two counties along the Arizona, United States-Sonora, Mexico border. Developed in 2000 by the Centers for Disease Control and Prevention, the School Health Index offers a guide to assist schools in evaluating and improving opportunities for physical activity and good nutrition for their students.
Context
Between 2000 and 2003, a total of 13 schools from five school districts in two counties participated in the School Health Index project despite academic pressures and limited resources.
Methods
The Border Health Strategic Initiative supported the hiring and training of an external coordinator in each county who was not part of the school system but who was an employee in an established community-based organization. The coordinators worked with the schools to implement the School Health Index, to develop action plans, and to monitor progress toward these goals.
Consequences
The School Health Index process and school team participation varied from school to school. Individual plans were different but all focused on reducing in-school access to unhealthy foods, identified as high-fat and/or of low nutritional value. Ideas for acting on this focus ranged from changing the content of school lunches to discontinuing the use of nonnutritious foods as classroom rewards. All plans included recommendations that could be implemented immediately as well as those that would require planning and perhaps the formation and assistance of a subcommittee (e.g., for developing or adopting a district-wide health curriculum).
Interpretation
After working with the School Health Index, most schools made at least one immediate change in their school environments. The external coordinator was essential to keeping the School Health Index results and action plans on the agendas of school administrators, especially during periods of staff turnover. Staff turnover, lack of time, and limited resources resulted in few schools achieving longer-term policy changes.
PMCID: PMC1323322  PMID: 15670472

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