Harnessing complexity: taking advantage of context and relationships in dissemination of school-based interventions.

Schools and school systems are increasingly asked to use evidence-based strategies to promote the health and well-being of students. The dissemination of school-based health promotion research, however, offers particular challenges to conventional approaches to dissemination. Schools and education systems are multifaceted organizations that sit within constantly shifting broader contexts. This article argues that health promotion dissemination needs to be rethought for school communities as complex systems and that this requires understanding and harnessing the dynamic ecology of the sociopolitical context. In developing this argument, the authors draw on their experience of the dissemination process of a multilevel school-based intervention in a complex educational context. Building on this experience, they argue for the need to move beyond conventional dissemination strategies to a focus on active partnerships between developers and users of school-based intervention research and offer a conceptual tool for planning dissemination.

Promoting social inclusion in schools: a group-randomized trial of effects on student health risk behavior and well-being.

OBJECTIVES: We sought to test the efficacy of an intervention that was designed to promote social inclusion and commitment to education, in reducing among students health risk behaviors and improving emotional well-being. METHODS: The design was a cluster-randomized trial in 25 secondary schools in Victoria, Australia. The subjects were 8th-grade students (aged 13 to 14 y) in 1997 (n=2545) and subsequent 8th-grade students in 1999 (n=2586) and 2001 (n=2463). The main outcomes were recent substance use, antisocial behavior, initiation of sexual intercourse, and depressive symptoms. RESULTS: At 4-year follow-up, the prevalence of marked health risk behaviors was approximately 20% in schools in the comparison group and 15% in schools in the intervention group, an overall reduction of 25%. In ordinal logistic regression models a protective effect of intervention was found for a composite measure of health risk behaviors in unadjusted models (odds ratio [OR]= 0.69; 95% confidence interval [CI]= 0.50, 0.95) and adjusted models (OR= 0.71; CI =0.52, 0.97) for potential confounders. There was no evidence of a reduction in depressive symptoms. CONCLUSION: The study provides support for prevention strategies in schools that move beyond health education to promoting positive social environments.

Patient safety: a view from Down Under.

The patient safety program at the Royal Children's Hospital, Melbourne has been running for more than 10 years. The hospital is in the State of Victoria, a state that has a long history of investigating child death, enacting legislation to reduce childhood injury, and providing a centralized tertiary care service. The close interaction between the hospital and the community provides opportunities for shared learning in pediatric patient safety to continually improve childhood outcomes.

Teenage drinking and the onset of alcohol dependence: a cohort study over seven years.

AIM: To determine whether adolescent alcohol use and/or other adolescent health risk behaviour predisposes to alcohol dependence in young adulthood. DESIGN: Seven-wave cohort study over 6 years. PARTICIPANT: A community sample of almost two thousand individuals followed from ages 14-15 to 20-21 years. OUTCOME MEASURE: Diagnostic and Statistical Manual volume IV (DSM-IV) alcohol dependence in participants aged 20-21 years and drinking three or more times a week. FINDINGS: Approximately 90% of participants consumed alcohol by age 20 years, 4.7% fulfilling DSM-IV alcohol dependence criteria. Alcohol dependence in young adults was preceded by higher persisting teenage rates of frequent drinking [odds ratio (OR) 8.1, 95% confidence interval (CI) 4.2, 16], binge drinking (OR 6.7, 95% CI 3.6, 12), alcohol-related injuries (OR 4.5 95% CI 1.9, 11), intense drinking (OR 4.8, 95% CI 2.6, 8.7), high dose tobacco use (OR 5.5, 95% CI 2.3, 13) and antisocial behaviour (OR 5.9, 95% CI 3.3, 11). After adjustment for other teenage predictors frequent drinking (OR 3.1, 95% CI 1.2, 7.7) and antisocial behaviour (OR 2.4, 95% CI 1.2, 5.1) held persisting independent associations with later alcohol dependence. There were no prospective associations found with emotional disturbance in adolescence. CONCLUSION: Teenage drinking patterns and other health risk behaviours in adolescence predicted alcohol dependence in adulthood. Prevention and early intervention initiatives to reduce longer-term alcohol-related harm therefore need to address the factors, including alcohol supply, that influence teenage consumption and in particular high-risk drinking patterns.

The Gatehouse Project: can a multilevel school intervention affect emotional wellbeing and health risk behaviours?

STUDY OBJECTIVE: The aim of this study was to determine the effect of a multilevel school based intervention on adolescents' emotional wellbeing and health risk behaviours. DESIGN: School based cluster randomised controlled trial. Students were surveyed using laptop computers, twice in the first year of intervention and annually thereafter for a further two years. SETTING: Secondary schools. PARTICIPANTS: 2678 year 8 students (74%) participated in the first wave of data collection. Attrition across the waves was less than 3%, 8%, and 10% respectively with no differential response rate between intervention and control groups at the subsequent waves (98% v 96%; 92% v 92%, and 90% v 89% respectively). MAIN RESULTS: A comparatively consistent 3% to 5% risk difference was found between intervention and control students for any drinking, any and regular smoking, and friends' alcohol and tobacco use across the three waves of follow up. The largest effect was a reduction in the reporting of regular smoking by those in the intervention group (OR 0.57, 0.62, and 0.72 at waves 2, 3, and 4 respectively). There was no significant effect of the intervention on depressive symptoms, and social and school relationships. CONCLUSIONS: While further research is required to determine fully the processes of change, this study shows that a focus on general cognitive skills and positive changes to the social environment of the school can have a substantial impact on important health risk behaviours.

Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health, and academic outcomes.

PURPOSE: To examine associations between social relationships and school engagement in early secondary school and mental health, substance use, and educational achievement 2-4 years later. METHODS: School-based longitudinal study of secondary school students, surveyed at school in Year 8 (13-14-years-old) and Year 10 (16-years-old), and 1-year post-secondary school. A total of 2678 Year 8 students (74%) participated in the first wave of data collection. For the school-based surveys, attrition was <10%. Seventy-one percent of the participating Year 8 students completed the post-secondary school survey. RESULTS: Having both good school and social connectedness in Year 8 was associated with the best outcomes in later years. In contrast, participants with low school connectedness but good social connectedness were at elevated risk of anxiety/depressive symptoms (odds ratio [OR]: 1.3; 95% confidence interval [CI]: 1.0, 1.76), regular smoking (OR: 2.0; 95% CI: 1.4, 2.9), drinking (OR: 1.7; 95% CI: 1.3, 2.2), and using marijuana (OR: 2.0; 95% CI: 1.6, 2.5) in later years. The likelihood of completing school was reduced for those with either poor social connectedness, low school connectedness, or both. CONCLUSIONS: Overall, young people's experiences of early secondary school and their relationships with others may continue to affect their moods, their substance use in later years, and their likelihood of completing secondary school. Having both good school connectedness and good social connectedness is associated with the best outcomes. The challenge is how to promote both school and social connectedness to best achieve these health and learning outcomes.

Sustainability of change with quality general practitioner education in adolescent health: a 5-year follow-up.

OBJECTIVE: To determine whether improvements gained in general practitioners' (GPs') self-perceived competency, attitudes and knowledge after an intervention in adolescent health care designed with evidence-based strategies in continuing medical education, are maintained longterm, 5 years post intervention. The intervention was designed with evidence-based strategies in continuing medical education. DESIGN: We carried out a follow-up postal survey of the cohort of metropolitan Australian GPs trained in the intervention 5 years previously. Measures Subsets of the original measures, used in the randomised controlled trial of the intervention, were selected to re-assess the GPs by postal survey. Self-perceived competency, attitude and knowledge were measured. Doctors were also asked about further training in adolescent health over the 5 years since the intervention and about self-reported practice. RESULTS: A total of 46 of 54 (85%) of the original intervention group returned a questionnaire. Scores at 5 years were all higher than at baseline (P < 0.01) and improvements were sustained in all measures from 12 months to 5 years after the intervention. In all, 25/46 (54%) doctors had received further training in related areas over the 5 years, but this did not improve sustainability. A total of 45/46 (98%) reported maintaining their clinical approach to youth and 22/46 (46%) reported maintaining practices to address systemic barriers to adolescent health care access. CONCLUSIONS: Quality education designed according to evidence-based strategies of effectiveness has advantages for longterm sustainability.