School health promotion and fruit and vegetable consumption in secondary schools: a repeated cross-sectional multilevel study.

BACKGROUND: Worldwide, recommendations for fruit and vegetable consumption are not met, which can cause chronic diseases. Especially adolescence is an important phase for the development of health behaviours. Therefore, in the Netherlands, the Healthy School program was established to aid schools in promoting healthy lifestyles among their students. We examined to what extent the variation between secondary schools regarding students' fruit and vegetable consumption could be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. Additionally, we examined whether Healthy School certification was related to the outcomes, and whether the association differed for subgroups. METHODS: We performed a repeated cross-sectional multilevel study. We used data from multiple school years from the national Youth Health Monitor on secondary schools (grades 2 and 4, age ranged from approximately 12 to 18 years) of seven Public Health Services, and added data with regard to Healthy School certification, general school characteristics and school population characteristics. We included two outcomes: the number of days a student consumed fruit and vegetables per week. In total, we analysed data on 168,127 students from 256 secondary schools in the Netherlands. RESULTS: Results indicated that 2.87% of the variation in fruit consumption and 5.57% of the variation in vegetable consumption could be attributed to differences at the school-level. Characteristics related to high parental educational attainment, household income, and educational track of the students explained most of the variance between schools. Additionally, we found a small favourable association between Healthy School certification and the number of days secondary school students consumed fruit and vegetables. CONCLUSIONS: School population characteristics explained more variation between schools than Healthy School certification and general school characteristics, especially indicators of parental socioeconomic status. Nevertheless, Healthy School certification seemed to be slightly related to fruit and vegetable consumption, and might contribute to healthier dietary intake. We found small differences for some subgroups, but future research should focus on the impact in different school contexts, since we were restricted in the characteristics that could be included in this study.

School health promotion and the consumption of water and sugar-sweetened beverages in secondary schools: a cross-sectional multilevel study.

BACKGROUND: Overweight among adolescents remains a serious concern worldwide and can have major health consequences in later life, such as cardiovascular diseases and cancer. Still, 33% of secondary school adolescents in the Netherlands consume sugar-sweetened beverages daily and over 26% do not consume water every day. The Dutch Healthy School program was developed to support schools in stimulating healthier lifestyles by focusing on health education, school environments, identifying students' health problems, and school policy. We examined the variation between secondary schools regarding the daily consumption of water and sugar-sweetened beverages and whether this variation can be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. METHODS: We performed a cross-sectional multilevel study. We used data from the national Youth Health Monitor of 2019 on secondary schools (grades 8 and 10, age range about 12 to 18 years) of seven Public Health Services and combined these with information regarding Healthy School certification and general school- and school population characteristics. Our outcomes were daily consumption of water and sugar-sweetened beverages. In total, data from 51,901 adolescents from 191 schools were analysed. We calculated the intraclass correlation to examine the variation between schools regarding our outcomes. Thereafter, we examined whether we could explain this variation by the included characteristics. RESULTS: The school-level explained 4.53% of the variation in the consumption of water and 2.33% of the variation in the consumption of sugar-sweetened beverages. This small variation in water and sugar-sweetened consumption could not be explained by Healthy School certification, yet some general school- and school population characteristics did: the proportion of the school population with at least one parent with high educational attainment, the educational track of the adolescents, urbanicity (only for water consumption) and school type (only for sugar-sweetened beverages consumption). CONCLUSIONS: The low percentages of explained variation indicate that school-level characteristics in general (including Healthy School certification) do not matter substantially for the daily consumption of water and sugar-sweetened beverages. Future research should examine whether school health promotion can contribute to healthier lifestyles, and if so, under which level of implementation and school conditions.

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

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

The Role of School Health Promotion in Students' Dietary Intake during School Hours: A Qualitative Comparative Analysis.

Many children in the Netherlands do not adhere to dietary guidelines. Therefore, the Healthy School (HS) program stimulates healthier dietary intake of students through schools. However, evaluating the effectiveness of school health promotion in improving dietary intake is challenging due to the influence of contextual factors. Qualitative Comparative Analysis (QCA) considers these contextual factors. Therefore, we performed a QCA to examine which (combinations of) contextual factors contribute to the healthier dietary intake of students during school hours in primary schools (approximate age range children 4-12 years) and secondary schools (age range 12-18 years) when implementing the HS program for nutrition. Data were collected mainly through interviewing school staff and a school-level questionnaire in fifteen primary schools and twelve secondary schools. We included five factors for primary schools: implementation of the HS program for nutrition, degree of implementation, socioeconomic status, parental support, and student support. For secondary schools, we included school environment instead of parental and student support. For primary schools, the best results were obtained if the HS program for nutrition was implemented in high socioeconomic status schools with a combination of high implementation, parental support, and student support. Findings indicate that if secondary schools have an impeding environment and low socioeconomic status, implementation of the HS program for nutrition can result in healthier dietary intake.