The "Planning Health in School" Programme (PHS-pro) to Improve Healthy Eating and Physical Activity: Design, Methodology, and Process Evaluation.

Few interventions have successfully promoted healthy eating and active living among children with effective changes in anthropometric health outcomes. Well-designed interventions involving multiple strategies to convert the knowledge already available into action are needed for preventing childhood obesity. In this study, an educational programme called "Planning Health in School" (PHS-pro) was designed, implemented and evaluated to contribute to the prevention of obesity in childhood. The PHS-pro aimed at improving the eating behaviours and lifestyles of Portuguese grade-6 children towards healthier nutritional status. This paper describes and evaluates the PHS-pro concerning: (i) the research design within the theoretical framework grounded on "The Transtheoretical Model" and the stages of change; (ii) the educational components and the application of the participatory methodology to engage children to meet their needs, as active participants in their change process; and (iii) the process evaluation of the intervention. The implementation of the PHS-pro took into account the views and inputs of the participants for evaluating the educational components that should be considered in the designing of interventions aiming to be effective strategies. From the health promotion perspective, this study is important because it examines new approaches and pathways to effectively prevent overweight and obesity in children.

Defining Life Skills in health promotion at school: a scoping review.

Background: Life Skills have been central to Health Promotion interventions and programmes with children and adolescents for over 40 years. School is a strategic setting for Life Skills education. Recently, policy-and decision-makers have focused on Life Skills development for youth. Research on Life Skills has gained momentum. Different terms are used to discuss and define Life Skills. Research identifies a lack of conceptual definition. The purpose of this study is to identify the definitions in the literature in English and French, and to reach a conceptual and consensual definition. Method: The Scoping Review methodology was used. Three research questions aim to identify how Life Skills are defined in the field of health promotion at school, to see whether a conceptual and consensual definition exists, and, if relevant, to propose a conceptual definition. The search was conducted in 5 databases by 3 reviewers. This study focused on full-text publications in English or French, human studies, health promotion in school, school pupils, teacher training, and with a definition of Life Skills. Publications on after-school activities, higher education outside teacher training, adult education, other than peer-reviewed scientific papers were excluded. Results: 48 publications were included in English and 7 in French. NVIVO was used to determine and compare the French and English terms used for Life Skills and their definitions. According to the three research questions, (i) the terms used to define Life Skills are diverse and numerous, with different purposes at school in relation to health promotion, and different taxonomies, and relate to different areas of research; (ii) no consensual, conceptual definition of Life Skills was found; (iii) further semantic, epistemological and ontological clarifications are required. Conclusion: Some conceptual definitions of Life Skills exist without consensus. Life Skills being at the crossroads between different fields could explain this and is illustrated by the multiplicity and diversity of the terms employed, and the various taxonomies and purposes used at school in health promotion. This may also explain why they are difficult to evaluate. Defining Life Skills consensually cannot be achieved due to the diversity of research perspectives from different fields.

The Impact of the 'Planning Health in School' Programme on a Pair of Twins with Obesity.

This case study describes the impact of the 'Planning Health in School' programme (PHS-pro) on the nutritional status and lifestyle behaviours of two twins with obesity. As part of a larger research project involving 449 adolescents in grade-6, PHS-pro aims at preventing obesity and guiding children towards healthy behaviours. Twins were evaluated for anthropometric measurements-height, weight, body mass index (BMI), waist circumference (WC), and lifestyle behaviours before (baseline) and after (8 months) PHS-pro and at a follow-up (one-year later). At the baseline, both twins were obese according to the international cut-off points of Cole. After PHS-pro, improvements in anthropometric parameters were found: the boy decreased his BMI by 10% and lost 9.0 cm in WC, while remaining obese; the girl decreased her BMI by 8% and lost 8.7 cm in WC, changing to the overweight category. At the follow-up, a slight increase in the anthropometric parameters was found in both twins; however, they did not return to the baseline values. The programme successfully promoted positive changes in behaviours and improved nutritional status, showing the long-term effects of the PHS-pro. Although it is a school-based intervention to prevent obesity, the PHS-pro is helpful in weight reduction even in children already with obesity.

Effectiveness of the "Planning Health in School" Programme on Children's Nutritional Status.

Effective interventions for guiding children to change behaviours are needed to tackle obesity. We evaluated the effectiveness of the 'Planning Health in School' programme (PHS-pro) on children's nutritional status. A non-randomised control group pretest-posttest trial was conducted at elementary schools of a sub-urban municipality in Porto's metropolitan area (Portugal). A total of 504 children of grade-6, aged 10-14, were assigned in two groups: children of one school as the intervention group (IG), and three schools as the control group (CG). Anthropometric measures included height, weight, waist circumference (WC), BMI and waist-to-height ratio (WHtR), and lifestyle behaviours (self-reported questionnaire) were assessed at baseline and after PHS-pro. IG children grew significantly taller more than CG ones (p < 0.001). WC had reduced significantly in IG (-0.4 cm) whereas in the CG had increased (+0.3 cm; p = 0.015), and WHtR of IG showed a significant reduction (p = 0.002) compared with CG. After PHS-pro, IG children consumed significantly fewer soft drinks (p = 0.043) and ate more fruit and vegetables daily than CG. Physical activity time increased significantly in IG (p = 0.022), while CG maintained the same activity level. The PHS-pro did improve anthropometric outcomes effectively leading to better nutritional status and appears to be promising in reducing overweight and obesity.

Children Learn, Children Do! Results of the "Planning Health in School", a Behavioural Change Programme.

The 'Planning Health in School' programme (PHS-pro) is a behavioural change intervention to assess and improve the eating habits of children, particularly the intake of fruit and vegetables, and to guide them towards healthy choices. The programme and its educational components are based on the Transtheoretical Model of stages of change to integrate nutritional literacy and build up problem-solving and decision-making skills. Children (n = 240, ages 10-12) of one large suburban school in Porto's metropolitan area (Portugal) were evaluated throughout PHS-pro implementation during one school year in a repeated time-series design. Children's outcome evaluations were conducted through seven 3-day food records for nine eating behaviour, documented after each learning module and through participatory activities which analysed attitudes, preferences and expectations. Changes were observed in children's eating behaviour, supported by changes in motivation as perceived in their attitudes and expectations. Significant changes were found in a higher consumption of vegetable soup (p = 0.003), milk products (p = 0.024), and fruit (p = 0.008), while the consumption of high-energy dense food (p = 0.048) and soft drinks (p = 0.042) significantly decreased. No positive effects on fried food, water, vegetables and bread consumption were found. The PHS-pro intervention proved to be effective in developing healthy eating behaviour in young people.

Educação para a saúde nas escolas portuguesas: diretrizes dos setores da saúde e da educação / Health education in Portuguese schools: guidelines from the health and education sectors / Educación para la salud en las escuelas portuguesas: directrices para los sectores de la salud y la educación

Enquadramento: Em Portugal, todas as escolas do ensino básico e secundário são consideradas Escolas Promotoras de Saúde. Objetivos: Analisar as linhas orientadoras para a implementação de escolas promotoras de saúde, emanadas pelos setores da saúde e da educação e verificar se se coadunam com as linhas orientadoras internacionais. Metodologia: Estudo de natureza qualitativa, com recurso a análise de conteúdo dos documentos oficiais utilizando o software NVivo® 11 Pro. Resultados: Ambos os setores (saúde e educação) preocupam-se com as Medidas a adotar para proporcionar condições de organização e de cooperação; têm os Objetivos claramente delineados e coincidentes; consideram relevante as Metodologias/estratégias ativas, especialmente a metodologia por projeto; apresentam Áreas/temas de intervenção idênticas e consideram a Avaliação essencialmente quantitativa. Conclusão: Os documentos da saúde e da educação são convergentes e complementares, havendo articulação entre ambos os setores para uma eficiente implementação de escolas promotoras de saúde.

Background: In Portugal, all elementary and secondary schools are considered to be Health Promoting Schools. Objective: To analyze the guidelines for the implementation of health promoting schools, issued by the health and education sectors, and assess whether they are consistent with international guidelines. Methodology: Qualitative study, with content analysis of official documents using NVivo®11 Pro software. Results: Both sectors (health and education) care about the Measures to be taken in order to provide organizational and cooperative conditions; define the Objectives clearly, which are coincident; consider active Methodologies/strategies, particularly project methodologies; present similar Areas/themes of intervention; and consider the Assessment essentially quantitative. Conclusion: The health and education documents are convergent and complementary, with articulation between both sectors for an efficient implementation of health promoting schools.

Marco contextual: En Portugal, todas las escuelas de enseñanza primaria y secundaria se consideran escuelas promotoras de la salud. Objetivos: Analizar las líneas orientadoras para implementar escuelas promotoras de la salud, emitidas por los sectores de la salud y la educación, y verificar si están acordes con las líneas orientadoras internacionales. Metodología: Estudio cualitativo, para el cual se utilizó el análisis de contenido de documentos oficiales con el software NVivo® 11 Pro. Resultados: Ambos sectores (salud y educación) se ocupan de las Medidas por adoptar para proporcionar condiciones organizativas y de cooperación; tienen los Objetivos claramente delineados y coincidentes; consideran relevantes las Metodologías/estrategias activas, especialmente la metodología por proyecto; presentan Áreas/temas de intervención idénticos y consideran la Evaluación esencialmente cuantitativa. Conclusión: Los documentos de salud y educación son convergentes y complementarios, con articulación entre ambos sectores para una implementación eficiente de las escuelas promotoras de la salud.

Costs and benefits of a school-based health intervention in Portugal.

School-based programmes for preventing childhood obesity have been shown to be effective in improving eating habits and nutritional status, but few intervention programmes with a controlled design have included an economic evaluation. In this study, we conducted a cost-consequence analysis to evaluate the costs and the health benefits of the 'Planning Health in School' programme (PHS-pro) implemented in the Northern region of Portugal to 449 children of 10-14 years old. Previous study has showed that after PHS-pro, several anthropometric measures significantly improved in the intervention group (height, waist circumference and waist-height ratio) compared with the control group, followed by significant improvements on soft drinks, fruit and vegetables daily consumptions. Costs were estimated according the two phases of the programme: designing and preparation of schools, and school setting implementation, and included all the direct costs on human and material resources. PHS-pro total costs were estimated as 7915.53€/year with an intervention cost of 36.14€/year/child attending the programme. This is much lower than the direct costs for treating an obese adult in Portugal, which was calculated as 3849.15€/year. A scale-up costing projection for implementing the PHS-pro to a larger young population was estimated to be even lower: 18.18€/year/child. This cost-consequence analysis provided evidence that the PHS-pro was economically feasible especially if compared with the medical costs for treating adult obesity. The PHS-pro can be a beneficial investment and may give a promising contribution to addressing overweight over childhood and adolescence, which are developmental stages that determine adulthood chronic diseases.

Generic health literacy measurement instruments for children and adolescents: a systematic review of the literature.

BACKGROUND: Health literacy is an important health promotion concern and recently children and adolescents have been the focus of increased academic attention. To assess the health literacy of this population, researchers have been focussing on developing instruments to measure their health literacy. Compared to the wider availability of instruments for adults, only a few tools are known for younger age groups. The objective of this study is to systematically review the field of generic child and adolescent health literacy measurement instruments that are currently available. METHOD: A systematic literature search was undertaken in five databases (PubMed, CINAHL, PsycNET, ERIC, and FIS) on articles published between January 1990 and July 2015, addressing children and adolescents ≤18 years old. Eligible articles were analysed, data was extracted, and synthesised according to review objectives. RESULTS: Fifteen generic health literacy measurement instruments for children and adolescents were identified. All, except two, are self-administered instruments. Seven are objective measures (performance-based tests), seven are subjective measures (self-reporting), and one uses a mixed-method measurement. Most instruments applied a broad and multidimensional understanding of health literacy. The instruments were developed in eight different countries, with most tools originating in the United States (n = 6). Among the instruments, 31 different components related to health literacy were identified. Accordingly, the studies exhibit a variety of implicit or explicit conceptual and operational definitions, and most instruments have been used in schools and other educational contexts. While the youngest age group studied was 7-year-old children within a parent-child study, there is only one instrument specifically designed for primary school children and none for early years. CONCLUSIONS: Despite the reported paucity of health literacy research involving children and adolescents, an unexpected number of health literacy measurement studies in children's populations was found. Most instruments tend to measure their own specific understanding of health literacy and not all provide sufficient conceptual information. To advance health literacy instruments, a much more standardised approach is necessary including improved reporting on the development and validation processes. Further research is required to improve health literacy instruments for children and adolescents and to provide knowledge to inform effective interventions.

Health literacy in childhood and youth: a systematic review of definitions and models.

BACKGROUND: Children and young people constitute a core target group for health literacy research and practice: during childhood and youth, fundamental cognitive, physical and emotional development processes take place and health-related behaviours and skills develop. However, there is limited knowledge and academic consensus regarding the abilities and knowledge a child or young person should possess for making sound health decisions. The research presented in this review addresses this gap by providing an overview and synthesis of current understandings of health literacy in childhood and youth. Furthermore, the authors aim to understand to what extent available models capture the unique needs and characteristics of children and young people. METHOD: Six databases were systematically searched with relevant search terms in English and German. Of the n = 1492 publications identified, N = 1021 entered the abstract screening and N = 340 full-texts were screened for eligibility. A total of 30 articles, which defined or conceptualized generic health literacy for a target population of 18 years or younger, were selected for a four-step inductive content analysis. RESULTS: The systematic review of the literature identified 12 definitions and 21 models that have been specifically developed for children and young people. In the literature, health literacy in children and young people is described as comprising variable sets of key dimensions, each appearing as a cluster of related abilities, skills, commitments, and knowledge that enable a person to approach health information competently and effectively and to derive at health-promoting decisions and actions. DISCUSSION: Identified definitions and models are very heterogeneous, depicting health literacy as multidimensional, complex construct. Moreover, health literacy is conceptualized as an action competence, with a strong focus on personal attributes, while also recognising its interrelatedness with social and contextual determinants. Life phase specificities are mainly considered from a cognitive and developmental perspective, leaving children's and young people's specific needs, vulnerabilities, and social structures poorly incorporated within most models. While a critical number of definitions and models were identified for youth or secondary school students, similar findings are lacking for children under the age of ten or within a primary school context.

Construção e validação de questionário para análise de concepções bioéticas / Construction and validation of a questionnaire for the analysis of bioethical conceptions / Construcción y validación de un cuestionario para análisis de concepciones bioéticas

Neste artigo objetivamos descrever as etapas do processo de elaboração de um questionário quantitativo que permita investigar as concepções sobre valores bioéticos inerentes à atividade científica. Validado semântica e estatisticamente, o questionário foi desenvolvido tendo por base a escala do tipo Likert. A relevância deste instrumento se dá pelo fato de que, diferentemente do que ocorre nos países europeus, as pesquisas quantitativas educacionais no Brasil têm pouca tradição. Este trabalho destina-se, portanto, a subsidiar o uso de métodos quantitativos nas pesquisas em Educação, que carecem de instrumentos deste tipo.

En este trabajo se describen las etapas del desarrollo de un cuestionario cuantitativo que permite investigar las concepciones acerca de los valores bioéticos inherentes a la actividad científica. Este cuestionario fue validado estadísticamente y semánticamente, y fue desarrollado tomando como base la escala de Likert. La relevancia de este instrumento está dada por el hecho de que, a diferencia de lo que ocurre en los países europeos, la investigación cuantitativa en Brasil tiene poca tradición educativa. Este trabajo tiene por objeto, por tanto, subsidiar el uso de los métodos cuantitativos en la investigación en educación, que carecen de tales herramientas.

In this paper we describe the stages of a quantitative questionnaire development that allows the investigation of conceptions about bioethical values inherent to the scientific activity. This questionnaire was statistically and semantically validated and developed according to the Likert scale. The relevance of this instrument is given by the fact that, unlike what happens in European countries, quantitative research in Brazil has little educational traditions. Therefore, this work is intended to subsidize the use of quantitative methods in Education research that lack such tools.

In search of a health education model: teachers' conceptions in four Mediterranean countries.

School programs are defined to promote the health of the pupils and to develop their competencies so that they can adopt behaviors favorable to their health. With the European project FP6 Biohead-Citizen (2004-2007), we analyzed the conceptions of teachers as regards health education, in France, Lebanon, Morocco and Tunisia, in reference to the biomedical model and the social health model. These four countries were selected because their school curricula represented different models of health education. Lebanon and Tunisia addressed health education with the biomedical model. In Morocco, the curriculum was also primarily based on the biomedical model and enclosed a few instructions issued from the social health model. In France, the health education curriculum declared an approach based on the health promotion model. Our study was based on multivariate statistical analyses of questionnaires filled out by 2537 in-service and pre-service teachers. Our analysis showed that the conceptions of the teachers concerning health education were not structured and related to a specific model. We also found that the dominating factors of influence on the choices expressed with regards to health education were, among different sociocultural variables, the religion, the home country, and, to a lesser extent, the level of training. Thus, the conceptions of the teachers were not integrated into comprehensive approaches but related to individual characteristics. Consequently health education implementation would require thorough training for pre-service and in-service teachers and should also explicitly take into account their conceptions and values.

The future of health promotion in schools goes through the strengthening of teacher training at a global level.

Schools are considered to be settings for both health education and health promotion. But the core business of schools is actually focused on educational outcomes, not reducing health problems. In most countries, schools give low priority to health promotion, and school staffs, mainly teachers, are not aware of their role in health promotion. Studies show that teachers who have received health promotion training tend to be involved more frequently in health promotion projects and have a more comprehensive approach to health education. Pre-service and in-service staff training is then a main challenge. This is the reason why we have launched an initiative to join international forces to strengthen and advocate for teacher training in health promotion. The main goals are to develop research, affirm and reinforce the work done in teacher training in health promotion, support the institutes/colleges/universities in the provision of pre-service and in-service teacher training and stimulate international partnership work.