A school-based food and nutrition education intervention increases nutrition-related knowledge and fruit consumption among primary school children in northern Ghana.

BACKGROUND: Providing children with the opportunity to learn about nutrition is critical in helping them establish a healthy lifestyle and eating behaviours that would remain with them till adulthood. We determined the effect of a school-based food and nutrition education (SFNE) intervention on the nutrition-related knowledge, attitudes, dietary habits, physical activity levels and the anthropometric indices (BMI-for-age z scores, %Body fat and waist circumference) of school-age children in northern Ghana. METHODS: Following a controlled before-and-after study design, we recruited school-age children in primary 4 and 5 from public and private schools and assigned them non-randomly to intervention and control groups (4 schools total). A SFNE intervention called 'Eat Healthy, Grow Healthy (EHGH)' was implemented in intervention schools. Components of the intervention included children, teachers, school officials, and the school environment. Nutrition education didactic sessions, active discussions, nutrition games, charades, art work, and physical activity sessions were among the teaching and learning activities implemented. At 0 and 6 months, primary (anthropometry) and secondary (fruit, vegetable, and breakfast consumption) outcomes were obtained. RESULTS: Mean BMI-for-age z-scores did not differ significantly between intervention and control groups (F1,261 = 0.45, P = 0.503, η2 = 0.01). However, significantly greater nutrition-related knowledge scores were recorded in the intervention group than in the control group at post-intervention (M = 6.07 SD = 2.17 vs. M = 5.22 SD = 1.92; p = 0.002). Mean number of days intervention children consumed fruits differed across time (F1, 263 = 33.04, p = 0.002, η2 = 0.04) but not between the control and intervention groups (F1, 263 = 0.28, p = 0.60, η2 = 0.00). CONCLUSIONS: The EHGH intervention had positive effects on the nutrition-related knowledge and the consumption of fruits among children although it did not impact their anthropometric indices.

Obesity and risk of hypertension in preadolescent urban school children: insights from Pakistan.

BACKGROUND: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in urban Karachi, Pakistan. METHODS: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescents aged 6-11 years, attending two private schools conducted from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. RESULTS: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension at followup (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) at follow up in the final model. CONCLUSION: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension or prehypertension at followup within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Quality of Health Education Teacher Preparation Program Curricula Throughout the United States.

BACKGROUND: Undergraduate majors in education, specifically in school health education (HE), have declined considerably in the United States. Reductions in state and federal funding for K-12 public education and increased demands on educators to prioritize standardized academic outcomes versus focusing on the whole child encompass many factors leading to fewer qualified teachers and reduced quality of HE delivery within schools. METHODS: A content analysis of over 300 HE teacher preparation programs throughout the United States was conducted from 2019 to 2020 to assess available and required curriculum for pre-service HE teachers. Seven curriculum areas were reviewed: nutrition, physical activity (PA) and physical education (PE), HE, chronic disease management (CDM), social emotional learning and mental health (SEL/MH), drug abuse and tobacco prevention (DA/TP), and a methods course in teaching HE. RESULTS: Findings indicated program type influenced course offerings, with stand-alone HE and joint HE/PE programs providing the most comprehensive curriculum. Most programs required courses in general HE, PA and PE, and nutrition. Programs were deficient in offering courses in CDM, DA/TP, and SEL/MH. CONCLUSION: This article contains recommendations to improve the quality of HE delivery in public schools, for example by ensuring that school health educators are trained in providing skills-based HE to youth, which can assist in addressing child and youth health outcomes (eg, CDM, mental health) for the nation.

Engaging School Champions in the Implementation of a Research Study in Historically Marginalized School Communities.

Community engagement in research improves uptake of health interventions and health outcomes among marginalized populations. Researchers from school-based health centers serving marginalized communities in Miami, Florida fostered community engagement in COVID-19 research and health education through collaboration with school staff and student "champions" from June 2021 to June 2023. Evaluations completed by champions assessed acceptability, feasibility, and recommendations for improvements. Overall satisfaction was high among champions. We elaborate on lessons learned and future directions for this type of research collaboration. (Am J Public Health. 2024;114(8):789-793. https://doi.org/10.2105/AJPH.2024.307711).

Umbrella review of international evidence for the effectiveness of school-based physical activity interventions.

BACKGROUND: Obesity and physical inactivity among children and young people are public health concerns. Despite the wide variety of interventions available to promote physical activity, little is known about which interventions are most effective. This review aimed to evaluate the existing literature on school-based interventions that aim to increase physical activity among children and young people aged 6 to 18 years. METHODS: A systematic review of reviews was undertaken. We searched for systematic reviews and meta-analyses published between December 2017 and January 2024 using databases such as PubMed, Scopus, and CINAHL. Titles and abstracts were independently screened by two reviewers, who also conducted data extraction and quality assessments. We focused on outcomes like changes in physical activity levels and body mass index to assess the effectiveness of the interventions. RESULTS: A total of 23 reviews examining school-based physical activity interventions met the inclusion criteria, comprising 15 systematic reviews and 8 meta-analyses. All reviews (N = 23) were implemented in the school setting: three in primary schools, seven in secondary schools, and thirteen targeted both primary and secondary schools. The findings demonstrated that six reviews reported a statistical increase in physical activity levels among the target population, and one review found a decrease in body mass index. The most promising interventions focused on physical activity included within the school curriculum and were characterised as long-term interventions. 20 out of 23 reviews assessed the quality of primary studies. CONCLUSION: Some interventions were promising in promoting physical activity among school-aged children and young people such as Daily Mile, Active Break, and Active transport while multi-component interventions seem to be positively effective in reducing BMI. Future efforts should focus on long-term, theory-driven programmes to ensure sustainable increases in physical activity.

Moving towards health promoting schools: effectiveness of an educational intervention to improve knowledge, attitude and beliefs regarding heart attack, and CPR knowledge in high school students in Lebanon.

Background: Health promoting schools (HPS) prioritize the health of students and community. One important target of HPS is noncommunicable diseases (NCDs), including prevention of heart attacks, due to their burden on healthcare. Objective: This study assesses the effectiveness of an educational intervention to promote knowledge of signs and symptoms, beliefs and attitudes towards heart attack, and promote knowledge of Cardiopulmonary resuscitation (CPR). Methods: The intervention consisted of a 6-minute educational video between a pre-and post-survey. Among other questions, the survey included the Calgary Charter on Health literacy scale, the acute coronary syndrome response index questionnaire, and items assessing knowledge of CPR. Results: A total of 401 high school students participated (58.9% females). Few students had adequate baseline knowledge of heart attack symptoms (22%) and CPR (7%). The sample showed moderate level of health literacy (12 ± 2.7). Chest pain was the most identified symptom (95%) while abdominal pain was the least identified (14.25%). The intervention significantly increased knowledge, beliefs and attitudes towards heart attack, and knowledge of CPR (p < 0.001). Following the intervention, 83.2% of students demonstrated sufficient knowledge of heart attack symptoms, and 45% exhibited adequate knowledge of CPR. Variables predictive of better attitude, in other words higher confidence in recognizing and reacting to symptoms of heart attack, included having higher health literacy and prior knowledge of risk factors (p < 0.05). Needing help reading medical instructions sometimes predicted worse belief in their capacity to act if they experienced or witnessed a heart attack [score (p < 0.05)]. It was also predictive of worse attitude towards heart attack (OR = 0.18). Conclusion: High school students in Lebanon lack appropriate knowledge, attitudes, and beliefs toward heart attack, and lack CPR qualifications. Scale up of this educational initiative, along with training of teachers and school personnel, can be used as part of a holistic HPS program aimed at raising awareness of heart attack and first responder preparedness.

Promoting wellbeing within the Health Promoting Schools framework: Could life skills be a means rather than an end?

This paper explores the evolution and challenges of health promotion in educational settings, focusing on the Health Promoting Schools framework. Central to this approach is the empowerment of students through participatory strategies and community engagement to address health determinants and reduce inequities. Well-being, a subjective and multifaceted concept, is crucial for student success, with positive school climates playing a key role. Additionally, life skills (LS) are identified as potential tools for promoting student well-being, though their definition and assessment remain ambiguous. The paper concludes by highlighting the need for further research and clarity in order to maximize the impact of health promotion efforts in schools.

Psychosocial competences in the continuing training of French National Education professionals in 2024: A major issue in promoting health in school environment.

OBJECTIVE: Promoting health, and in particular developing psychosocial competences, at school encourages the emancipation of pupils and creates a favourable school environment. Furthermore, by helping to improve academic success, they improve pupils' overall health. However, school professionals need to be trained to develop students' psychosocial competences. The aim of this study was to describe the perceptions of French National Education professionals who have attended in-service training in psychosocial competences. METHOD: This research adopts a mixed methodology. An online questionnaire was administered to 304 professionals in order to measure their levels of satisfaction and professional development following the training. Then, 14 professionals took part in individual semi-structured interviews to discuss their needs and the obstacles and levers they encountered in reinvesting what they had learned into their professional practice. RESULTS: The quantitative data showed that the professionals have an average satisfaction rating ranging from 6.96 to 8.22 out of 10 depending on the variable measured, but that they need to discover more tools and practices to develop psychosocial competences (79.28%). The qualitative data reveal that continuing training enables National Education professionals to exchange ideas with their peers and to review their posture (78.57%). They were able to experiment with psychosocial competences according to their needs and modified their practices as a result of the training (57.14%). CONCLUSION: This study suggests that continuing training in psychosocial competences leads to changes in the attitudes and practices of National Education professionals, despite significant heterogeneity in terms of the length of training. Future research could focus on the actual practices of professionals trained in the development of psychosocial competences in order to assess the difficulties they encounter.

The prevention school diary: Evaluability assessment of a widely adopted intervention in Ile-de-France.

OBJECTIVES: The prevention school diary is distributed each year to children aged between 10 and 11 years old by La Ligue contre le cancer, a French association promoting prevention and research against cancer. While they write their homework in the diary, children can learn about a range of health determinants. This diary promotes health in a fun and educational way, as it integrates drawings made by children about the different themes covered by the diary. This paper aims to present the evaluability assessment of this intervention in Ile-de-France (Paris area), where it is already widely deployed. MATERIAL AND METHODS: We have traced the history of the prevention school diary and assessed how it is currently used in Ile-de-France by leading interviews with county committees of La Ligue contre le cancer. Successive versions of the diary and results of teacher satisfaction surveys were examined. All information collected was integrated into a logic model, which characterizes the main components, actors, and effects of the intervention. RESULTS: The prevention school diary was created in the West of France in the late 90s. It was then implemented in Paris and extended to other counties of Ile-de-France. Currently, six counties collaborate on the production of a common diary. Whereas it only dealt with tobacco consumption at the beginning, the prevention school diary now covers nutrition, physical activity, sun exposure, sleep and screen use, addiction, as well as safety in some counties. Three levels of intervention have been identified, depending on whether or not the distribution of the diary is followed by the production of drawings for the next edition or health education sessions. The expected effects of the prevention school diary have been integrated into a logic model emphasizing children, school, and family level. Outcomes include Capabilities (knowledge and skills), Opportunities, and Motivation to adopt healthy Behaviours, according to the theoretical model of behaviour change COM-B. CONCLUSION: The evaluability assessment phase enabled us to gain a better understanding of the conditions under which the intervention is deployed, and thus to identify the factors to be considered for a broad assessment of its effectiveness. It is especially important since the intervention is already well established in Ile-de-France.

An ecological dynamics approach to promote physical literacy and well-being of primary school children: a cluster randomised controlled trial study protocol.

BACKGROUND: Little is known about the impact of an ecological dynamics (ED) intervention (EDI) on primary school children's physical literacy and well-being in the Hong Kong context. The aim of this project is to introduce a physical literacy and well-being framework through an EDI that allows primary school children to develop good physical activity (PA) and daily behavioural habits. METHODS AND ANALYSIS: A four-arm (cluster) randomised controlled trial will be conducted to examine the effect of EDI on physical literacy and well-being in primary schools located in each of the 18 administrative districts of Hong Kong. Four classes in senior primary students (grade 4) at each school will be randomly assigned to the four different conditions. These participating schools will be equipped with sit-stand desks, PA recess facility and equipment, and sleep pillows. The research team will adopt both objective measures (aerobic fitness, fundamental movement skills, daily behaviour-physical activity and cognitive function) and self-reported measures (perceived physical literacy, quality of life, sleep quality) covering the elements and domains of physical literacy and well-being to examine the effects of EDIs at four time points, including baseline assessment, 3 months after intervention, postintervention and 3-month follow-up assessment. One-way analyses of variance (ANOVAs) will be used to test for differences in the baseline characteristics of participants between groups. Repeated measure ANOVAs and MANCOVA, with time (baseline, after intervention and follow-up) as within-subjects factor, and intervention group as between-subjects factors, will be used to evaluate the effects of different interventions on the students' physical literacy and well-being. A Bonferonni correction to the p value will be calculated to adjust for multiple tests. ETHICS AND DISSEMINATION: Ethical approval was sought from the Joint CUHK-NTEC Clinical Research Ethics Committee in Hong Kong (CREC Ref.No.:2024.027). The finding of this study will be disseminated via peer-reviewed journals, international conference presentations and academic lectures. For secondary analysis of the data, please contact the corresponding author for permission. TRIAL REGISTRATION NUMBER: ISRCTN84025914.

Violence outcomes in later adolescence with the Good School Toolkit-Primary: a nonrandomized controlled trial in Uganda.

BACKGROUND: We sought to determine whether the Good School Toolkit-Primary violence prevention intervention was associated with reduced victimisation and perpetration of peer and intimate partner violence four years later, and if any associations were moderated by sex and early adolescent: family connectedness, socio-economic status, and experience of violence outside of school. METHODS: Drawing on schools involved in a randomised controlled trial of the intervention, we used a quasi-experimental design to compare violence outcomes between those who received the intervention during our trial (n = 1388), and those who did not receive the intervention during or after the trial (n = 522). Data were collected in 2014 (mean age 13.4, SD 1.5 years) from participants in 42 schools in Luwero District, Uganda, and 2018/19 from the same participants both in and out of school (mean age 18, SD: 1.77 years). We compared children who received the Good School Toolkit-Primary, a whole school violence prevention intervention, during a randomised controlled trial, to those who did not receive the intervention during or after the trial. Outcomes were measured using items adapted from the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. We used mixed-effect multivariable logistic regression, with school fitted as a random-effect to account for clustering. RESULTS: 1910 adolescents aged about 16-19 years old were included in our analysis. We found no evidence of an average long-term intervention effect on our primary outcome, peer violence victimization at follow-up (aOR = 0.81, 95%CI = 0.59-1.11); or for any secondary outcome. However, exposure to the intervention was associated with: later reductions in peer violence, for adolescents with high family connectedness (aOR = 0.70, 95% CI 0.49 to 0.99), but not for those with low family connectedness (aOR = 1.07, 95% CI 0.69 to 1.6; p-interaction = 0.06); and reduced later intimate partner violence perpetration among males with high socio-economic status (aOR = 0.32, 95%CI 0.11 to 0.90), but not low socio-economic status (aOR = 1.01 95%CI 0.37 to 2.76, p-interaction = 0.05). CONCLUSIONS: Young adolescents in connected families and with higher socio-economic status may be better equipped to transfer violence prevention skills from primary school to new relationships as they get older. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01678846, registration date 24 August 2012. Protocol for this paper:  https://www.researchprotocols.org/2020/12/e20940 .

Evaluation of "Cognitive Behavioral Intervention for Trauma in Schools" (CBITS) in child welfare programs in Germany: study protocol of a randomized controlled trial.

BACKGROUND: Children and adolescents growing up in child welfare institutions have been frequently exposed to traumatic events and psychosocial stress and show elevated rates of mental disorders. Yet, there is a lack of empirically supported treatments to provide adequate mental health care for children in care suffering from trauma-related mental disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety. The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is an evaluated trauma-focused cognitive-behavioral group intervention, which has proven to be effective in reducing symptoms of PTSD, depression, and anxiety for traumatized children in group settings. The trial will evaluate the effectiveness of the CBITS intervention as an outreach treatment compared with an enhanced treatment-as-usual condition (TAU +) within the German mental health and child welfare system. METHODS: In a randomized controlled trial (RCT) involving N = 90 children and adolescents, we will compare CBITS with TAU + . Participants between 8 and 16 years, reporting at least one traumatic event and moderate posttraumatic stress symptoms (PTSS), will be randomized within their child welfare institution to either one of the conditions using a CATS-2 severity-stratified block randomization. Assessments will take place at baseline, as well as 4 months and 10 months after baseline. The primary outcome is the severity of PTSS after 4 months. Secondary outcomes are depression, anxiety, irritability/anger, quality of life, and global functioning level. DISCUSSION: The results of our trial will provide evidence regarding effective treatment options for traumatized children in care, which represent an understudied population with limited access to mental health care. Additionally, it could serve as a blueprint for implementing trauma-focused outreach group treatments for children in care and increase the accessibility to appropriate treatment. TRIAL REGISTRATION: Clinical Trials.gov NCT06038357 D. September 13, 2023.

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.

Gender-transformative school-based sexual health intervention: study protocol for a randomized controlled trial.

BACKGROUND: There is general agreement that sexuality is a central aspect of human development; it is key in sexual health and reproductive education during adolescence. However, in spite of the existing interventions on this topic and the evidence generated, the inclusion of a gender focus in sexuality is relatively recent and there is little evidence available, thus structured and corroborated interventions with a gender-transforming perspective in sexuality are required. METHODS: We will use a mixed method experimental design with a parallel cluster-randomized trial (GRTs) that will evaluate the effectiveness of a comprehensive gender-transformative intervention of sexual education (ENFOCATE -Focus-on-), which will be complemented with qualitative studies to understand the implementation process. The participants will be 609 10th and 11th-grade students. The randomization will be by grade, and the data will be collected at three moments (pre-intervention, post-intervention, and a 3-month follow-up). DISCUSSION: Comprehensive, gender-focused, and culturally pertinent interventions in sexuality are needed for adolescents of countries with high, middle, and low incomes. These produce better results in terms of sexual health, and including a gender-transformative focus contributes to equity in health. Focus-on is unique since it uses a comprehensive gender-transformative intervention in sexual education that will allow putting into practice a program based both on international evidence and that which arises from the object population. It also uses a culturally-sensitive focus, since it is designed based on the characteristics of the object population; it will allow adapting some activities to the needs of the context in which it is developed. TRIAL REGISTRATION: The study was prospectively registered on June 6, 2023, at ClinicalTrials.gov ID: NCT05896540. Protocol version number 1.0. May 22, 2023.

The Role of School-based Interventions and Communities for Mental Health Prevention, Tiered Levels of Care, and Access to Care.

This article highlights the key role of schools in addressing rising mental health disorders among youth. It champions collaboration between health and educational sectors, emphasizing child and adolescent psychiatrists' significant contribution to school-based mental health literacy and interventions. This article encourages for child and adolescent psychiatrists' involvement in policy advocacy for accessible and inclusive mental health care, championing sustainable mental health services through advocating for funding, training, and policy support.

The Social and Emotional Education and Development intervention to address wellbeing in primary school age children: the SEED cluster RCT.

Background: Stronger social and emotional well-being during primary school is positively associated with the health and educational outcomes of young people. However, there is little evidence on which programmes are the most effective for improving social and emotional well-being. Objective: The objective was to rigorously evaluate the Social and Emotional Education and Development (SEED) intervention process for improving pupils' social and emotional well-being. Design: This was a stratified cluster randomised controlled trial with embedded process and economic evaluations. Thirty-eight primary schools were randomly assigned to the SEED intervention or to the control group. Hierarchical regression analysis allowing for clustering at school learning community level was conducted in R (statistical package). Setting: The SEED intervention is a whole-school intervention; it involved all school staff and two cohorts of pupils, one starting at 4 or 5 years of age and the second starting at 8 or 9 years of age, across all 38 schools. Participants: A total of 2639 pupils in Scotland. Intervention: The SEED intervention used an iterative process that involved three components to facilitate selection and implementation of school-based actions: (1) questionnaire completion, (2) benchmarked feedback to all staff and (3) reflective discussions (all staff and an educational psychologist). Main outcome measure: The primary outcome was pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score when pupils were 4 years older than at baseline. Results: The primary outcome, pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score at follow-up 3, showed improvements for intervention arm pupils, compared with those in the control arm [relative risk -1.30 (95% confidence interval -1.87 to -0.73), standardised effect size -0.27 (95% confidence interval -0.39 to -0.15)]. There was no evidence of intervention effects according to deprivation: the results were significant for both affluent and deprived pupils. Subgroup analysis showed that all effect sizes were larger for the older cohort, particularly boys [relative risk -2.36 (95% confidence interval -3.62 to -1.11), standardised effect size -0.42 (95% confidence interval -0.64 to -0.20)]. Although there was no statistically significant difference in incremental cost and quality-adjusted life-years, the probability that the intervention is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year was high, at 88%. Particularly valued mechanisms of the SEED intervention were its provision of time to reflect on and discuss social and emotional well-being and its contribution to a culture of evaluating practice. Limitations: It was a challenge to retain schools over five waves of data collection. Conclusions: This trial demonstrated that the SEED intervention is an acceptable, cost-effective way to modestly improve pupil well-being and improve school climate, particularly for older boys and those with greater levels of psychological difficulties. It was beneficial during the transition from primary to secondary school, but this diminished after 6 years. The SEED intervention can be implemented alongside existing systems for addressing pupil well-being and can be complementary to other interventions. Future work: Assess whether or not the SEED intervention has a beneficial impact on academic attainment, is transferable to other countries and other organisational settings, would be strengthened by adding core training elements to the intervention process and is transferable to secondary schools. Understand the gender differences illustrated by the outcomes of this trial. Conduct further statistical research on how to handle missing data in longitudinal studies of complex social interventions. Trial registration: This trial is registered as ISRCTN51707384. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 10/3006/13) and is published in full in Public Health Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

We studied the Social and Emotional Education and Development (SEED) primary school intervention to see if it could improve the social and emotional well-being of pupils in Scotland. The SEED intervention is a process with several elements. We collected information from school pupils, staff and parents, and assessed if the schools involved were happy, safe and caring environments. We sought to highlight any strengths or weaknesses in how each school approaches social and emotional well-being. The SEED intervention also measures the social and emotional well-being of pupils. This includes pupils' strengths and difficulties, confidence, understanding of emotions and quality of relationships. We gave the information back to each school to help them decide what they can do to improve the social and emotional well-being of their pupils. We gave schools a guide to available resources, reviewed according to how well they are known to work elsewhere. The same social and emotional well-being measurements were repeated every 1 or 2 years, to see if any improvements had been made, and to guide any further adaptions of activities. The study ran in 38 schools over 7 years; half of the schools were randomly selected to receive the SEED intervention and half carried on as normal. Two age groups of pupils were recruited; the younger group was aged 4 or 5 years and the older group was aged 8 or 9 years at the start of the study. We found that the SEED intervention did slightly improve social and emotional well-being. Improvements were greater for older pupils, in particular for boys, and lasted beyond their transition from primary to secondary school. We also found that it was cost-effective for schools to run the SEED intervention. Schools valued the structure and shared ownership associated with the process. We concluded that the SEED intervention is an acceptable way to modestly improve pupil well-being and school ethos.

Reading the signs in health visits-Perspectives of adolescents with migration experiences on encounters with school nurses.

AIM: To explore the experiences of health visits within the school health services from the perspective of adolescents with migration experiences. DESIGN: A descriptive qualitative study. METHODS: Data were collected using focus groups and semi-structured individual interviews with adolescents with migration experiences aged 13-17 years old. Analysis was conducted using reflexive thematic analysis. RESULTS: The results described adolescents reading the signs in the guided interaction between them and the school nurses. Reading the signs illustrated the adolescents' continuous interpretation of the interaction with the school nurse, and their decisions on how to respond throughout the health visit. These interpretations influenced the adolescents' shifting willingness to talk about their health and how they adapted to the space of participation provided by the school nurse. The interpretation also influenced their experiences of health visits as focusing on their health without making them feel singled out. CONCLUSION: Although individual considerations might be warranted in health visits with adolescents with migration experiences, the results indicate that similarities in intrapersonal communication in various encounters between adolescents and health professionals might be greater than any differences. Healthcare encounters with adolescents with migration experiences might thus need to be conducted with an awareness that adolescents read the signs in the guided interaction and that similarities in this interaction are greater than any differences.