Association of cannabis, cannabidiol and synthetic cannabinoid use with mental health in UK adolescents.

BACKGROUND: Cannabis has been associated with poorer mental health, but little is known of the effect of synthetic cannabinoids or cannabidiol (often referred to as CBD). AIMS: To investigate associations of cannabis, synthetic cannabinoids and cannabidiol with mental health in adolescence. METHOD: We conducted a cross-sectional analysis with 13- to 14-year-old adolescents across England and Wales in 2019-2020. Multilevel logistic regression was used to examine the association of lifetime use of cannabis, synthetic cannabinoids and cannabidiol with self-reported symptoms of probable depression, anxiety, conduct disorder and auditory hallucinations. RESULTS: Of the 6672 adolescents who participated, 5.2% reported using of cannabis, 1.9% reported using cannabidiol and 0.6% reported using synthetic cannabinoids. After correction for multiple testing, adolescents who had used these substances were significantly more likely to report a probable depressive, anxiety or conduct disorder, as well as auditory hallucinations, than those who had not. Adjustment for socioeconomic disadvantage had little effect on associations, but weekly tobacco use resulted in marked attenuation of associations. The association of cannabis use with probable anxiety and depressive disorders was weaker in those who reported using cannabidiol than those who did not. There was little evidence of an interaction between synthetic cannabinoids and cannabidiol. CONCLUSIONS: To our knowledge, this study provides the first general population evidence that synthetic cannabinoids and cannabidiol are associated with probable mental health disorders in adolescence. These associations require replication, ideally with prospective cohorts and stronger study designs.

Study design of 'Move More': Development and feasibility of a social-prescribing intervention to increase physical activity among inactive Danes.

AIM: This paper describes the design of the 'Move More' study, which aims to develop and assess the feasibility of a social-prescribing intervention to increase physical activity among physically inactive Danes. BACKGROUND: Physical inactivity constitutes a public-health challenge in Denmark. Social prescribing may be a promising tool to tackle physical inactivity by linking physical activity support from general practitioners with community-based activities in sports clubs, as this may help physically inactive citizens become more physically active. Given the range of stakeholders and behaviours required for social prescribing of physical activity, an intervention that harnesses this approach may constitute a complex intervention. The methods and decisions made in the stages of developing complex interventions are seldom reported. The present study enabled us to describe how co-creation can be used in a pragmatic development process for a complex intervention that considers the needs of stakeholders and the conditions of the delivery context. METHODS: The study is based on the core elements of the development and feasibility phases of the Medical Research Council Framework for Developing and Evaluating Complex Interventions. Additionally, it is informed by a framework for the co-creation and prototyping of public-health interventions, drawing from a scoping review, stakeholder consultations and co-creation workshops. Ultimately, a feasibility study will be conducted to refine the programme theory by introducing the proposed intervention in case studies. PERSPECTIVES: The study will result in a prototype intervention manual and recommendations for implementation of an adapted social-prescribing intervention targeting physical inactivity in Denmark.

A mixed-methods process evaluation of the feasibility and acceptability of involving community and peer role models within a physical activity intervention for primary-school-aged girls (the CHARMING study).

BACKGROUND: Role models have been identified as a potential means to tackle the persisting low levels of physical activity among young girls. The aim of this research was to explore the involvement of community- and peer role models within the CHARMING (CHoosing Active Role Models to INspire Girls) intervention, an intervention which aims to increase and sustain physical activity among 9-10-year-old girls. The research questions were, is it feasible and acceptable to recruit role models? and what are the perceived barriers and facilitators to the inclusion of peer role models within the intervention? METHODS: A mixed methods process evaluation was embedded within a larger feasibility study, involving three secondary schools and four adjoining primary schools in South Wales, United Kingdom. One-to-one interviews were conducted with teachers (N = 10) across the seven schools and community role models (N = 10). Focus groups were conducted with 18 peer role models (older girls from adjoining secondary schools) and 18 girls aged 9-10-years who had participated in the intervention. Primary school teachers kept observation logs of each intervention session. A researcher completed observation logs of two random sessions per school. Qualitative data were analysed using thematic analysis with a combined deductive and inductive coding approach. Observation data were analysed using descriptive statistics. Data were triangulated and comparative analyses conducted across schools. RESULTS: Twenty-three peer role models (aged 12-16-years) and 16 community role models participated in intervention delivery. Overall, the inclusion of both types of role models was shown as acceptable and feasible within the CHARMING intervention. Observation data highlighted key areas (i.e., intervention components delivered inconsistently) for further qualitative exploration. Six themes were identified during analyses; reach and access, communication, logistics, existing systems, interpersonal relationships, and perceived impacts. Themes were intertwined across the barriers and facilitators of recruitment and implementation. Areas for future improvement were highlighted. CONCLUSIONS: Findings can be used to optimise the CHARMING intervention and inform wider interventions or policies employing several role models across settings to promote physical activity among children.

Study protocol of a mixed method pragmatic quasi-experimental trial to evaluate the day activity services targeted at older home care clients in Finland.

BACKGROUND: In Finland, the 'day activity service' is targeted at older home care clients who are unable to participate in other available activities due to poor health or functional disabilities. The aim of the day activity service is to support home care client's ability to live at home and to enhance their wellbeing and social inclusion. This mixed method study examines the effectiveness, cost-effectiveness and process of the day activity service. METHODS: The target sample size is 200 participants. The intervention group (n = 100) is composed of home care clients who begin to participate in the day activity service. The comparison group (n = 100) are home care clients who do not participate in the day activity service, and whose functioning and care needs are similar to the participants of the intervention group. The primary outcome is social inclusion (ESIS-scale). Secondary outcomes are loneliness (single item and De Jong Gierveld Loneliness Scale) and social care related quality of life (ASCOT). Baseline, three-month and six-month follow-up surveys are gathered from intervention and comparison group participants in order to compare outcomes between groups pre- and post-intervention. Costs of health and social services, based on administrative data, and the costs of the intervention are utilized in examining the cost-effectiveness of the intervention with the above-described measurements. Qualitative data are collected by interviewing the intervention participants (n = 10) and professionals working at the day activity centres and older people's services (4 focus groups) to explore the perceived outcomes and process of the intervention to find out how and why the intervention is effective or ineffective. DISCUSSION: The study seeks to produce a comprehensive understanding of the effectiveness, cost-effectiveness and implementation process of the day activity service. TRIAL REGISTRATION: ISRCTN13146087, Registration date 03/04/2022.

Mental health and life satisfaction among 10-11-year-olds in Wales, before and one year after onset of the COVID-19 pandemic.

BACKGROUND: In many countries, including in the United Kingdom (UK), COVID-19 social distancing measures placed substantial restrictions on children's lives in 2020 and 2021, including closure of schools and limitations on play. Many children faced milestones such as transition to secondary school having missed several months of face-to-face schooling in the previous academic years. METHODS: This paper examines change in mental health difficulties, life satisfaction, school connectedness, and feelings about transition to secondary school among 10-11-year-olds in Wales, UK, using data from repeat cross-sectional surveys before and after the onset of the COVID-19 pandemic. Participants were 4032 10-11-year-old schoolchildren. The first cohort completed a school-based survey in 2019 (prior to introduction of social distancing measures), and the second in 2021 (following full return to school after two rounds of school closure). RESULTS: The percentage of children reporting elevated emotional difficulties rose from 17% in 2019 to 27% in 2021 (Odds Ratio = 1.65; 95%CI = 1.23 to 2.20). There was no evidence of increased behavioural difficulties (OR = 1.04; 95%CI = 0.73 to 1.46). There was a tendency toward declines in life satisfaction in all analyses, but this intersected the null (OR = 0.86; 95%CI = 0.70 to 1.07). Children reported a high degree of school connectedness before and after the pandemic, with no evidence of change in ratings of teacher relationships, pupil relationships or pupil involvement in school life. There was no evidence of impacts of the pandemic on children's feelings about the transition to secondary school, with feelings becoming more positive as transition neared. Most findings were robust to a range of sensitivity analyses. CONCLUSIONS: Supporting children's emotional recovery from the COVID-19 pandemic is a public health priority requiring urgent and effective action at multiple levels of society. Maintaining connectedness to school through the pandemic may have played a role in preventing a steeper increase in child mental health difficulties.

From a research trial to routine practice: stakeholders' perceptions and experiences of referrals to the National Exercise Referral Scheme (NERS) in Wales.

BACKGROUND: Over ten years on from a randomised controlled trial and subsequent national roll-out, the National Exercise Referral Scheme (NERS) continues to be routinely delivered in primary care across Wales, UK. Few studies have revisited effective interventions years into their delivery in routine practice to understand how implementation, and perceived effects, have been maintained over time. This study explores perceptions and experiences of referral to NERS among referrers, scheme deliverers and patients. METHODS: Individual, semi-structured interviews were conducted with 50 stakeholders: scheme referrers (n = 9); scheme deliverers (n = 22); and referred patients (n = 19). Convenience sampling techniques were used to recruit scheme referrers and purposive sampling to recruit scheme deliverers and patients. Thematic analysis was employed. RESULTS: Analyses resulted in five key themes; referrer characteristics, geographical disparities in referral and scheme access, reinforcements for awareness of the scheme, patient characteristics and processes and context underpinning a referral. Overall there was a high concordance of views between all three stakeholder groups and barriers and facilitators were found to be entwined within and across themes. Referral barriers persisting since the earlier trial included a lack of consultation time and a lack of referral feedback. Newly identified barriers included a lack of scheme awareness and a referral system perceived to be time intensive and disjointed. Key referral facilitators included patient self-referrals, a growing scheme reputation and promotional activities of scheme deliverers. CONCLUSIONS: Findings provide evidence that could inform the further development of NERS and wider exercise referral schemes to ensure the referral process is timely, efficient and equitable.

Acceptability and Feasibility of Implementing Accelorometry-Based Activity Monitors and a Linked Web Portal in an Exercise Referral Scheme: Feasibility Randomized Controlled Trial.

BACKGROUND: Exercise referral schemes (ERSs) are recommended for patients with health conditions or risk factors. Evidence points to the initial effectiveness and cost-effectiveness of such schemes for increasing physical activity, but effects often diminish over time. Techniques such as goal setting, self-monitoring, and personalized feedback may support motivation for physical activity and maintenance of effects. Wearable technologies could provide an opportunity to integrate motivational techniques into exercise schemes. However, little is known about acceptability to exercise referral populations or implementation feasibility within exercise referral services. OBJECTIVE: To determine the feasibility and acceptability of implementing an activity-monitoring device within the Welsh National ERS to inform a decision on whether and how to proceed to an effectiveness trial. METHODS: We conducted a feasability randomized controlled trial with embedded mixed-methods process evaluation and an exploratory economic analysis. Adults (N=156) were randomized to intervention (plus usual practice; n=88) or usual practice only (n=68). Usual practice was a 16-week structured exercise program. The intervention group additionally received an accelerometry-based activity monitor (MyWellnessKey) and associated Web platform (MyWellnessCloud). The primary outcomes were predefined progression criteria assessing acceptability and feasibility of the intervention and proposed evaluation. Postal questionnaires were completed at baseline (time 0:T0), 16 weeks (T1), and 12 months after T0 (T2). Routine data were accessed at the same time-points. A subsample of intervention participants and scheme staff were interviewed following the initiation of intervention delivery and at T2. RESULTS: Participants were on average aged 56.6 (SD 16.3) years and mostly female (101/156, 64.7%) and white (150/156, 96.2%). Only 2 of 5 progression criteria were met; recruitment and randomization methods were acceptable to participants, and contamination was low. However, recruitment and retention rates (11.3% and 67.3%, respectively) fell substantially short of target criteria (20% and 80%, respectively), and disproportionally recruited from the least deprived quintile. Only 57.4% of intervention participants reported receipt of the intervention (below the 80% progression threshold). Less than half reported the intervention to be acceptable at T2. Participant and staff interviews revealed barriers to intervention delivery and engagement related to the device design as well as context-specific technological challenges, all of which made it difficult to integrate the technology into the service. Routinely collected health economic measures had substantial missing data, suggesting that other methods for collecting these should be used in future. CONCLUSIONS: To our knowledge, this is the first study to evaluate short- and long-term feasibility and acceptability of integrating wearable technologies into community-based ERSs. The findings highlight device- and context-specific barriers to doing this in routine practice, with typical exercise referral populations. Key criteria for progression to a full-scale evaluation were not met. TRIAL REGISTRATION: ISRCTN Registry ISRCTN85785652; http://www.isrctn.com/ISRCTN85785652.

Development of a framework for the co-production and prototyping of public health interventions.

BACKGROUND: Existing guidance for developing public health interventions does not provide information for researchers about how to work with intervention providers to co-produce and prototype the content and delivery of new interventions prior to evaluation. The ASSIST + Frank study aimed to adapt an existing effective peer-led smoking prevention intervention (ASSIST), integrating new content from the UK drug education resource Talk to Frank ( www.talktofrank.com ) to co-produce two new school-based peer-led drug prevention interventions. A three-stage framework was tested to adapt and develop intervention content and delivery methods in collaboration with key stakeholders to facilitate implementation. METHODS: The three stages of the framework were: 1) Evidence review and stakeholder consultation; 2) Co-production; 3) Prototyping. During stage 1, six focus groups, 12 consultations, five interviews, and nine observations of intervention delivery were conducted with key stakeholders (e.g. Public Health Wales [PHW] ASSIST delivery team, teachers, school students, health professionals). During stage 2, an intervention development group consisting of members of the research team and the PHW ASSIST delivery team was established to adapt existing, and co-produce new, intervention activities. In stage 3, intervention training and content were iteratively prototyped using process data on fidelity and acceptability to key stakeholders. Stages 2 and 3 took the form of an action-research process involving a series of face-to-face meetings, email exchanges, observations, and training sessions. RESULTS: Utilising the three-stage framework, we co-produced and tested intervention content and delivery methods for the two interventions over a period of 18 months involving external partners. New and adapted intervention activities, as well as refinements in content, the format of delivery, timing and sequencing of activities, and training manuals resulted from this process. The involvement of intervention delivery staff, participants and teachers shaped the content and format of the interventions, as well as supporting rapid prototyping in context at the final stage. CONCLUSIONS: This three-stage framework extends current guidance on intervention development by providing step-by-step instructions for co-producing and prototyping an intervention's content and delivery processes prior to piloting and formal evaluation. This framework enhances existing guidance and could be transferred to co-produce and prototype other public health interventions. TRIAL REGISTRATION: ISRCTN14415936 , registered retrospectively on 05 November 2014.

Exercise intensities of gardening tasks within older adult allotment gardeners in Wales.

Previous research has suggested that gardening activity could be an effective form of regular exercise for improving physical and psychological health in later life. However, there is a lack of data regarding the exercise intensities of various gardening tasks across different types of gardening and different populations. The purpose of this study was to examine the exercise intensity of gardening activity for older adult allotment gardeners in Wales, United Kingdom following a similar procedure used in previous studies conducted in the United States and South Korea by Park and colleagues (2008a; 2011). Oxygen consumption (VO2) and energy expenditure for six gardening tasks were measured via indirect calorimetery using the portable Oxycon mobile device. From these measures, estimated metabolic equivalent units (METs) were calculated. Consistent with Park et al. (2008a; 2011) the six gardening tasks were classified as low to moderate-high intensity physical activities based on their metabolic values (1.9-5.7 METs).

Association between cannabis potency and mental health in adolescence.

INTRODUCTION: In legal and illegal markets, high-potency cannabis (>10 % delta-9-tetrahydrocannabinol (THC)) is increasingly available. In adult samples higher-potency cannabis has been associated with mental health disorder but no studies have considered associations in adolescence. METHODS: A population-wide study compared no, low and high potency cannabis using adolescents (aged 13-14 years) self-reported symptoms of probable depression, anxiety, and auditory hallucinations. RESULTS: Of the 6672 participants, high-potency cannabis was used by 2.6 % (n=171) and low-potency by 0.6 % (n=38). After adjustment for sociodemographic factors, tobacco and alcohol use, in comparison to participants who had never used cannabis, people who had used high-potency but not low-potency cannabis were more likely to report symptoms of depression (odds ratio 1.59 [95 % confidence interval 1.06, 2.39), anxiety (OR 1.45, 95 % CI 0.96, 2.20), and auditory hallucinations (OR 1.56, 95 % CI 0.98, 2.47). CONCLUSIONS: High-potency cannabis use is associated with an increased risk of probable mental health disorders. Services and programming to minimise drug harms may need to be adapted to pay more attention to cannabis potency.

Development of a school-based programme for mental health promotion and prevention among adolescents in Nepal and South Africa.

Introduction: Adolescence is a critical time for mental health promotion and prevention and establishing healthy behaviours. Implementing universal, school-based psychosocial interventions can improve short- and long-term health trajectories for adolescents. While these interventions may offer important opportunities for fostering skills and relationships, few school-based interventions have been developed for and tested in low- and middle-income countries (LMICs) where adolescent mental health needs may be significant and under-served. This manuscript details the development of a multi-component, universal school-based intervention, Health Action in ScHools for a Thriving Adolescent Generation (HASHTAG), for adolescents aged 12-15 years in Nepal and South Africa. Methods and results: We describe HASHTAG's development over four phases, combining methods and results as each phase was iteratively conducted between 2018 and 2021. Phase 1 included a systematic review and components analysis, building from WHO guidelines for adolescent mental health. Seven components were strongly supported by the evidence: emotional regulation, stress management, mindfulness, problem-solving, interpersonal skills, assertiveness training, and alcohol and drug education. Phase 2 encompassed site selection, theory of change development, and formative research engagements; research teams in each site engaged adolescents and key adult stakeholders to identify priorities for intervention. Stakeholders voiced preferences for external facilitators and key content and delivery for intervention sessions. These findings informed Phase 3, a draft manual of HASHTAG, including a whole-school component, called Thriving Environment in Schools, and a classroom-based, six-session component, Thrive Together. In Phase 4, participants engaged in consultative workshops to review and contextualise content by country, preparing HASHTAG for implementation in a feasibility trial. Minor adaptations were made in Nepal, including using school nurses and adjusting take-home materials; both country's workshops identified practical considerations for implementing activities. Conclusions: HASHTAG was designed around core evidence-based components to increase translatability across LMICs, while enabling country-specific tailoring to enhance feasibility. Future research will test whether this multi-component, whole-school approach can improve adolescent mental health.

Association Between Gender Minority Status and Mental Health in High School Students.

PURPOSE: Adolescence is a phase when young people begin to explore their gender identity. Adolescents who identify as a gender minority are vulnerable to experiencing mental health problems due to stigmatization of their identity. METHODS: A population-wide study compared gender minority and cisgender students (aged 13-14 years) self-reported symptoms of probable depression, anxiety, and conduct disorder, and auditory hallucinations, including the distress and frequency of hallucinations. RESULTS: Gender minority students compared to cisgender students had four times the odds of reporting a probable depressive disorder, anxiety disorder, auditory hallucinations, but not conduct disorder. Of those who reported a hallucination, gender minority students were more likely to report hearing them daily but were no more likely to find them distressing. DISCUSSION: Gender minority students experience a disproportionate burden of mental health problems. Services and programming should be adapted to better support gender minority high-school students.

CHoosing Active Role Models to INspire Girls (CHARMING): protocol for a cluster randomised feasibility trial of a school-based, community-linked programme to increase physical activity levels in 9-10-year-old girls.

BACKGROUND: In the UK, there is evidence that girls' physical activity tends to decline to a greater extent than boys as they enter adolescence. 'Role models' could play a vital role in inspiring girls to become or remain physically active. The CHARMING Programme is a primary school-based community linked role-model programme, co-developed in 2016, with children, parents, schools and wider stakeholders. It involves different types of physical activity delivered for 1-h each week by a community provider and peer role models (e.g. older girls from secondary schools) joining in with the sessions. The programme ultimately aims to increase and sustain physical activity levels among 9-10-year-old girls. This study aims to assess the feasibility and acceptability of the CHARMING Programme and of evaluating it using a randomised trial. METHODS: This study is a feasibility cluster randomised controlled trial, with embedded process evaluation and health economic evaluation. Approximately 90 Year 5 (i.e. 9-10-year-old) girls will be recruited across six primary schools in Mid-South Wales. Participating schools will be allocated to the programme: control on a 2:1 basis; four intervention schools will run the CHARMING Programme and two will continue with usual practice. A survey and accelerometer will be administered at baseline and repeated at 12 months. Interviews and focus groups will be conducted post-intervention delivery. The primary aim is to assess feasibility of a future randomised trial via the recruitment of schools, participants and role models; randomisation; retention; reach; data collection completion rates; programme adherence; and programme fidelity, views on intervention acceptability and programme barriers and facilitators. Secondary aims are to evaluate established physical activity outcome measures for children plus additional health economic outcomes for inclusion in a future full-scale trial. DISCUSSION: The results of this study will inform decisions on whether and how to proceed to a full-scale evaluation of the effectiveness and cost-effectiveness of the CHARMING Programme to improve or sustain physical activity. TRIAL REGISTRATION: ClinicalTrials.gov ISRCTN36223327. Registered March 29, 2021.

Understanding implementation research collaborations from a co-creation lens: Recommendations for a path forward.

Increasing calls within the field of implementation science (IS) research seek to promote active engagement of diverse and often disenfranchised stakeholder voices to increase buy-in, fidelity, outcome relevance, and sustainment of evidence-based practices (EBPs). Including such voices requires cultural humility and the integration of multiple perspectives and values among organizations, groups, and individuals. However, the IS field lacks guidance for researchers on structuring collaborative approaches to promote a co-created process (i.e., synergistic approach to goal attainment). We contend that improved operationalization of co-created implementation collaborations is critical to sparking synergy and addressing differentials based on power, privilege, knowledge, and access to resources among stakeholders. These differentials can undermine future implementation and sustainment efforts if not addressed early in the research effort. An insufficient understanding of the guiding principles of co-created implementation collaborations may limit the scientific value of evaluation processes, and researchers' ability to replicate outcomes. We propose a perspective foregrounded in the concept of co-creation to guide the structuring of implementation collaboratives through five principles. We offer three case examples informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to illustrate the application of these co-creation principles. Lastly, we offer recommendations for promoting co-creation in IS research moving forward.

Sugar-sweetened beverage consumption from 1998-2017: Findings from the health behaviour in school-aged children/school health research network in Wales.

To date no study has examined time trends in adolescent consumption of sugar-sweetened beverages and energy drinks, or modelled change in inequalities over time. The present study aimed to fill this gap by identifying historical trends among secondary school students in Wales, United Kingdom. The present study includes 11-16 year olds who completed the Health Behaviour in School-aged Children (HBSC) survey and the Welsh School Health Research Network (SHRN) survey between 1998 to 2017. Multinomial regression models were employed alongside tests for interaction effects. A total of 176,094 student responses were assessed. From 1998 to 2017, the prevalence of daily sugar-sweetened beverage consumption decreased (57% to 18%) while weekly consumption has remained constant since 2006 (49% to 52%). From 2013 to 2017, daily consumption of energy drinks remained stable (6%) while weekly consumption reports steadily decreased (23% to 15%). Boys, older children and those from a low socioeconomic group reported higher consumption rates of sugar-sweetened beverages and energy drinks. Consumption according to socioeconomic group was the only characteristic to show a statistically significant change over time, revealing a widening disparity between sugar-sweetened beverage consumption rates of those from low and high socioeconomic groups. Findings indicate a positive shift in overall consumption rates of both sugar-sweetened beverages and energy drinks. Adolescents from a low socioeconomic group however were consistently shown to report unfavourable sugar-sweetened beverages consumption when compared to peers from high socioeconomic group. Given the established longer term impacts of sugar-sweetened beverage and energy drink consumption on adolescent health outcomes, urgent policy action is required to reduce overall consumption rates, with close attention to equity of impact throughout policy design and evaluation plans.

Socioeconomic status, mental wellbeing and transition to secondary school: Analysis of the School Health Research Network/Health Behaviour in School-aged Children survey in Wales.

Young people's wellbeing is often lowest where they assume a relatively low position within their school's socioeconomic hierarchy, for example, among poorer children attending more affluent schools. Transition to secondary school is a period during which young people typically enter an environment which is more socioeconomically diverse than their primary school. Young people joining a school with a higher socioeconomic status intake relative to their primary school may assume a relatively lowered position within their school's socioeconomic hierarchy, experiencing a detriment to their wellbeing as a consequence. This article draws on data from 45,055 pupils in Years 7 and 8, from 193 secondary schools in Wales, who completed the 2017 Student Health Research Network (SHRN) Student Health and Wellbeing (SHW) survey. Pupils reported which primary school they previously attended, and survey data on wellbeing were linked to publicly available data on the free school meal entitlement of schools attended. In cross-classified linear mixed-effects models, with primary and secondary school as levels, mental wellbeing varied significantly according to both primary and secondary school attended. A higher school-level deprivation was associated with worse mental wellbeing in both cases. Mental wellbeing was significantly predicted by the relative affluence of a child's primary and secondary school, with movement to a secondary school of higher overall socioeconomic status associated with lowered wellbeing. These findings highlight transition to secondary school as a key point in which socioeconomic inequality in wellbeing may widen, and thus as an important focal point for intervention to reduce health inequalities.

Testing the "Zero-Sum Game" Hypothesis: An Examination of School Health Policies and Practices and Inequalities in Educational Outcomes.

BACKGROUND: Health and education are intrinsically linked, while both are significantly patterned by socioeconomic status throughout the life course. Nevertheless, the impact of promoting health via schools on education is seen by some as a "zero-sum game"; ie, focusing resources on health improvement activity distracts schools from their core business of educating pupils, potentially compromising educational attainment. There is emerging evidence that school health improvement interventions may beneficially influence both health and attainment. However, few studies have examined the relationship between school health improvement activity and socioeconomic inequalities in educational attainment. METHODS: Wales-wide, school-level survey data on school health policies and practices was linked with routinely collected data on academic attainment. Primary outcomes included attendance and academic attainment at age 14 (Key Stage 3) and 16 (Key Stage 4). Linear regression models were constructed separately for high and low Free School Meal (FSM) schools, adjusting for confounders. Interaction terms were fitted to test whether there was an interaction between FSM, health improvement activity, and outcomes. RESULTS: There were positive associations between almost all school health variables and KS3 attainment among high, but not low FSM schools. Similarly, for attendance, there were positive associations of several health variables among high but not low FSM schools. There were no associations for KS4 attainment. CONCLUSIONS: Our findings did not support the "zero-sum game" hypothesis; in fact, among more deprived schools there was a tendency for better attendance and attainment at age 14 in schools with more embedded health improvement action.

Use of the School Setting During the Summer Holidays: Mixed-Methods Evaluation of Food and Fun Clubs in Wales.

OBJECTIVE: School summer holiday clubs in deprived areas of Wales were evaluated to examine opportunities for healthy eating and physical activity and explore delivery processes. METHODS: Ten Food and Fun clubs participated in 2016. Quantitative data (child and parent surveys; N = 196, N = 84) assessed the opportunity to provide children with breakfast and lunch. A sub-sample of children wore an accelerometer (N = 41) to evaluate the opportunity for achieving 1-hour of moderate to vigorous activity (MVPA) at club. Features of successful club delivery were identified through; focus groups (child and parent; N = 74, N = 69) and interviews (staff/volunteer; N = 32). RESULTS: Opportunities for healthy eating were delivered with high fidelity: 86% of children reported breakfast consumption and 75% eating a healthy lunch. On club days, children reported consuming fewer sugary snacks (66%), fewer sugary drinks (81%), and more fruits and vegetables (67%). About 71% of children achieved the recommended MVPA at club, with children engaging in more MVPA (+17 minutes/day, p < .01) on average compared to non-club days. Successful delivery processes were: use of school facilities and staff; flexible partnership-working; and whole family involvement. CONCLUSIONS: Schools appear to provide a suitable setting for the delivery of healthy eating and physical activity opportunities during school summer holidays.