Students' beliefs and behaviour regarding low-calorie beverages, sweets or snacks: are they affected by lessons on healthy food and by changes to school vending machines?

OBJECTIVE: To study the effects of school lessons about healthy food on adolescents' self-reported beliefs and behaviour regarding the purchase and consumption of soft drinks, water and extra foods, including sweets and snacks. The lessons were combined with the introduction of lower-calorie foods, food labelling and price reductions in school vending machines. DESIGN: A cluster-randomized controlled design was used to allocate schools to an experimental group (i.e. lessons and changes to school vending machines) and a control group (i.e. 'care as usual'). Questionnaires were used pre-test and post-test to assess students' self-reported purchase of extra products and their knowledge and beliefs regarding the consumption of low-calorie products. SETTING: Secondary schools in the Netherlands. SUBJECTS: Twelve schools participated in the experimental group (303 students) and fourteen in the control group (311 students). The students' mean age was 13.6 years, 71.5% were of native Dutch origin and mean BMI was 18.9 kg/m(2). RESULTS: At post-test, the experimental group knew significantly more about healthy food than the control group. Fewer students in the experimental group (43%) than in the control group (56%) reported bringing soft drinks from home. There was no significant effect on attitude, social norm, perceived behavioural control and intention regarding the consumption of low-calorie extra products. CONCLUSIONS: The intervention had limited effects on students' knowledge and self-reported behaviour, and no effect on their beliefs regarding low-calorie beverages, sweets or snacks. We recommend a combined educational and environmental intervention of longer duration and engaging parents. More research into the effects of such interventions is needed.

Effects of transfer-oriented curriculum on multiple behaviors in the Netherlands.

Many school health promotion curricula address a single health behavior, without paying attention to potential learning effects in associated behavioral domains. We developed an innovative curriculum about smoking and safe sex that also focused on promoting students' transfer of knowledge, skills and attitudes to other domains. In a quasi-experimental study involving 1107 students (Grades 7 and 8) in the Netherlands, the curriculum was compared with regular lessons about smoking and safe sex. The central research questions were to what extent the transfer-oriented curriculum: (i) had effects on psychosocial determinants and behaviors in the domains of smoking and safe sex, (ii) had effects on determinants and behaviors in three domains about which no lessons were taught (consumption of alcohol, fruit and breakfast). Multi-level analyses showed that the answer to both questions is positive. The results indicate that a transfer approach may have surplus value over the classic domain-specific approach and warrant further elaboration in the future.

Promoting the purchase of low-calorie foods from school vending machines: a cluster-randomized controlled study.

BACKGROUND: Vending machines account for food sales and revenue in schools. We examined 3 strategies for promoting the sale of lower-calorie food products from vending machines in high schools in the Netherlands. METHODS: A school-based randomized controlled trial was conducted in 13 experimental schools and 15 control schools. Three strategies were tested within each experimental school: increasing the availability of lower-calorie products in vending machines, labeling products, and reducing the price of lower-calorie products. The experimental schools introduced the strategies in 3 consecutive phases, with phase 3 incorporating all 3 strategies. The control schools remained the same. The sales volumes from the vending machines were registered. Products were grouped into (1) extra foods containing empty calories, for example, candies and potato chips, (2) nutrient-rich basic foods, and (3) beverages. They were also divided into favorable, moderately unfavorable, and unfavorable products. RESULTS: Total sales volumes for experimental and control schools did not differ significantly for the extra and beverage products. Proportionally, the higher availability of lower-calorie extra products in the experimental schools led to higher sales of moderately unfavorable extra products than in the control schools, and to higher sales of favorable extra products in experimental schools where students have to stay during breaks. Together, availability, labeling, and price reduction raised the proportional sales of favorable beverages. CONCLUSION: Results indicate that when the availability of lower-calorie foods is increased and is also combined with labeling and reduced prices, students make healthier choices without buying more or fewer products from school vending machines. Changes to school vending machines help to create a healthy school environment.

Differences in school environment, school policy and actions regarding overweight prevention between Dutch schools. A nationwide survey.

BACKGROUND: Schools are regarded as an important setting for the prevention of overweight. This study presents a nationally representative picture of the obesogenity of the school environment, the awareness of schools regarding overweight, and actions taken by the schools aiming at overweight prevention. In addition, differences between school levels were studied. METHODS: In 2006-2007, questionnaires were sent to all Dutch secondary schools (age group 12-18 years). Prevalences of the outcome variables were calculated for the schools in total and by school level. The association between school level and outcome variables were analysed by a log linear regression. RESULTS: Unhealthy foods and drinks are widely available at secondary schools. One third of the schools indicated that overweight has increased among students and half of the schools agreed that schools were (co)responsible for the prevention of overweight. Only 3% of the schools have a policy on overweight prevention. Small differences were observed between vocational education schools and higher education schools. The presence of vending machines did not differ by school level, but at vocational education schools, the content of the vending machines was less healthy. CONCLUSION: This study describes the current situation at schools which is essential for the development and evaluation of future overweight prevention policies and interventions. In general, secondary schools are not actively involved in overweight prevention and the nutritional environment at most schools could be improved. The small differences between school levels do not give reason for a differential approach for a certain school level for overweight prevention.

Effective elements of school health promotion across behavioral domains: a systematic review of reviews.

BACKGROUND: Most school health education programs focus on a single behavioral domain. Integrative programs that address multiple behaviors may be more efficient, but only if the elements of change are similar for these behaviors. The objective of this study was to examine which effective elements of school health education are similar across three particular behavioral domains. METHODS: A systematic review of reviews of the effectiveness of school-based health promotion programs was conducted for the domains of substance abuse, sexual behavior, and nutrition. The literature search spanned the time period between 1995 and October 2006 and included three databases, websites of review centers and backward search. Fifty-five reviews and meta-analyses met predetermined relevance and publication criteria and were included. Data was extracted by one reviewer and checked by a second reviewer. A standardized data extraction form was used, with detailed attention to effective elements pertaining to program goals, development, content, methods, facilitator, components and intensity. Two assessors rated the quality of reviews as strong, moderate or weak. We included only strong and moderate reviews in two types of analysis: one based on interpretation of conflicting results, the other on a specific vote-counting rule. RESULTS: Thirty six reviews were rated strong, 6 moderate, and 13 weak. A multitude of effective elements was identified in the included reviews and many elements were similar for two or more domains. In both types of analysis, five elements with evidence from strong reviews were found to be similar for all three domains: use of theory; addressing social influences, especially social norms; addressing cognitive-behavioral skills; training of facilitators; and multiple components. Two additional elements had positive results in all domains with the rule-based method of analysis, but had inconclusive results in at least one domain with the interpretation-based method of analysis: parent involvement and a larger number of sessions. CONCLUSION: Five effective elements of school health promotion were found to be similar across the three behavioral domains examined (substance abuse, sexual behavior, nutrition). An integrative program that addresses the three domains seems feasible. The five elements are primary candidates to include in programs targeting these behaviors.

Schools for health, education and development: a call for action.

In 2007, the World Health Organization, together with United Nations and international organization as well as experts, met to draw upon existing evidence and practical experience from regions, countries and individual schools in promoting health through schools. The goal of the meeting was to identify current and emerging global factors affecting schools, and to help them respond more effectively to health, education and development opportunities. At the meeting, a Statement was developed describing effective approaches and strategies that can be adopted by schools to promote health, education and development. Five key challenges were identified. These described the need to continue building evidence and capturing practical experience in school health; the importance of improving implementation processes to ensure optimal transfer of evidence into practice; the need to alleviating social and economic disadvantage in access to and successful completion of school education; the opportunity to harness media influences for positive benefit, and the continuing challenge to improve partnerships among different sectors and organizations. The participants also identified a range of actions needed to respond to these challenges, highlighting the need for action by local school communities, governments and international organizations to invest in quality education, and to increase participation of children and young people in school education. This paper describes the rationale for and process of the meeting and the development of the Statement and outlines some of the most immediate efforts made to implement the actions identified in the Statement. It also suggests further joint actions required for the implementation of the Statement.

A review of similarities between domain-specific determinants of four health behaviors among adolescents.

Schools are overloaded with health promotion programs that, altogether, focus on a broad array of behavioral domains, including substance abuse, sexuality and nutrition. Although the specific content of programs varies according to the domain focus, programs usually address similar concepts: knowledge, attitudinal beliefs, social influences and skills. This apparent conceptual overlap between behaviors and programs provides opportunities for a transfer-oriented approach which will stimulate students to apply the knowledge and skills they have learned in one domain (e.g. skills for resisting tobacco use) to other domains (e.g. alcohol, sex). A requirement for such an approach is that behaviors share at least some determinants. This review addresses this issue by examining similarities between domain-specific determinants of smoking, drinking, safe sex and healthy nutrition among adolescents. Recent empirical studies and reviews were examined. The results show that the following determinants are relevant to all four behaviors: beliefs about immediate gratification and social advantages, peer norms, peer and parental modeling and refusal self-efficacy. Several other determinants have been found to relate to at least two behaviors, e.g. health risk beliefs and parental norms. These results can be used for the development of a transfer-oriented school health promotion curriculum.

Clustering of health-related behaviors and their determinants: possible consequences for school health interventions.

Characterizing school health promotion is its category-by-category approach, in which each separate health-related behavior is addressed independently. Such an approach creates a risk that extra-curricular activities become overloaded, and that teaching staff are distracted by continuous innovations. Within the health promotion sector there are thus increasing calls for an integrative approach to health-related behaviors. However, a meaningful integrative approach to different lifestyles will be possible only if there is some clustering of individual health-related behaviors and if health-related behaviors have a minimum number of determinants in common. This systematic review aims to identify to what extent the four health-related behaviors smoking, alcohol abuse, safe sex and healthy nutrition cluster; and how their determinants are associated. Potentially modifiable determinants that offer clues for an integrative approach of school health-promotion programs are identified. Besides, the direction in which health educators should look for a more efficient instructional design is indicated.

The European Smoking Prevention Framework Approach (EFSA): an example of integral prevention.

A smoking prevention project in six European countries (European Smoking prevention Framework Approach) was developed, featuring activities for adolescents, schools and parents, including out-of-school activities. Consensus meetings resulted in agreement between the countries on goals, objectives and theoretical methods. Countries' specific objectives were also included. National diversities required country-specific methods to realize the goals and objectives. The community intervention trial was used as the research design. Since interventions took place at the community level, communities or regions were allocated at random to the experimental or control conditions. Complete randomization was achieved in four countries. At baseline, smoking prevalence among 23 125 adolescents at the start of the project was 5.6% for regular smoking and 4.0% for daily smoking. Smoking prevalence rates were higher among girls than boys in all countries as far as weekly smoking was concerned. Process evaluations revealed that the project's ambitions were high, but were limited by various constraints including time and delays in receiving funds. Future smoking prevention projects should aim to identify the effective components within the social influence approach as well as within broader approaches and on reaching sustained effects.