Background: The prevalence of low well-being, perceived stress and unhealthy behaviours is high among high school students, but few interventions have addressed these problems. The aim of this paper is to present a study protocol of a cluster randomised controlled trial evaluating the Healthy High School (HHS) intervention programme. The intervention programme is designed to improve well-being (primary outcome) by preventing 1) stress and promoting 2) sleep, 3) sense of community, 4) physical activity (PA) and 5) regular and healthy meals among high school students in Denmark. Methods: The development of the HHS study was guided by the Intervention Mapping protocol. The intervention comprises four components: 1) a teaching material, 2) a smartphone app, 3) a catalogue focusing on environmental changes, and 4) a peer-led innovation workshop aiming at inspiring students to initiate and participate in various movement activities. The HHS study employs a cluster-randomised controlled trial design. Thirty-one high schools across Denmark were randomly allocated to intervention (16 schools) or control (15 schools) groups. The study included all first-year students (~16 years of age) (n = 5976 students). Timeline: Intervention: August 2016-June 2017. Collection of questionnaire data: Baseline (August 2016), 1st follow-up (May 2017) and 2nd follow-up (April 2018). All students were invited to participate in a monthly sub-study about perceived stress using text messages for data collection (September 2016-June 2017). PA was objectively assessed among a sub-sample of students using accelerometers (Axivity, AX3) in August 2016 and May 2017. Primary outcome measures: Student well-being measured by the Cantril Ladder and the five item World Health Organisation Well-being Index (individual level outcomes). Secondary outcome measures: Stress (10-item Perceived Stress Scale), sleep (quantity and quality), PA (hours of moderate-to-vigorous PA per week, hours of daily sedentary time and average daily PA), meal habits (daily intake of breakfast, lunch, snacks and water), and strong sense of community in class and at school, respectively (individual level outcomes). The study encompasses process and effect evaluation as well as health economic analyses.
Objective: As alcohol is often consumed for social purposes, we aimed to explore how restrictions during the first Danish COVID-19 lockdown affected the alcohol use among adolescents aged 15–20. Method: In May 2020, 11,596 15- to 20-year-olds from two subpopulations answered a survey regarding their alcohol use and social life, as well as changes to these, during the Danish lockdown. Using survey data from all participants, we performed a multinomial logistic regression to assess the association between determinants of alcohol use and perceived change in alcohol use during the Danish lockdown. We used longitudinal data from one subpopulation ( n=1869) to perform negative binomial regressions exploring changes in frequency of alcohol use from 2019 to 2020. Results: Of all participants, 59% drank less, 75% had fewer in-person social interactions and 56% met more frequently online during lockdown. Girls were more likely than boys to have a perceived decrease in alcohol use during lockdown (odds ratio (OR)=1.41; 95% confidence interval (CI) 1.27–1.56). A perceived decrease in in-person social interaction during lockdown was associated with less drinking (OR=2.27; 95% CI 1.98–2.61), while a perceived increase in in-person social interaction during lockdown was associated with more drinking (OR=1.42; 95% CI 1.11–1.82) compared to unchanged drinking behaviour and social interaction. Conclusions: Adolescents in Denmark drank less during the Danish lockdown than before. Findings indicate that there is a close relationship between in-person social interactions and frequency of drinking. Drinking episodes when meeting online were rare and were not unambiguously associated with changes in drinking during lockdown.
Background Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up. Methods The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data. Results At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33). Conclusion No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting. Trial registration ISRCTN, ISRCTN43284296. Registered 28 April 2017 - retrospectively registered.
Process evaluation of public health interventions is important for understanding intervention results and can help explain why interventions succeed or fail. This study evaluated implementation of a school-based intervention combining educational and environmental strategies to prevent stress among Danish high school students. We investigated dose delivered, dose received, fidelity, appreciation, barriers and facilitators at the 15 intervention schools using mixed methods and multiple data sources: questionnaires among students, teachers and school coordinators; semi-structured interviews with school coordinators; telephone interviews with student counsellors; and focus group interviews with students and teachers. Implementation varied by schools and classes. Half of the intervention schools delivered the environmental strategies. For the educational strategies, dose delivered differed according to intervention provider. Students reported a lower dose received compared with dose delivered reported by school staff. Overall, student counsellors, school coordinators and students—especially those with low perceived stress—were satisfied with the stress preventive initiatives while teacher satisfaction varied. Five main barriers and three facilitators for implementation were identified. The use of multiple data sources and data methods created new knowledge of the implementation process which is important for the interpretation of effect evaluation and development of future interventions.
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