Effects of school-based physical activity interventions on mental health in adolescents: The School in Motion cluster randomized controlled trial

Purpose To investigate the effects of two school-based physical activity interventions on mental health in Norwegian adolescents. Methods Students from 29 lower secondary schools in Norway (n = 2084; 14–15 years; 49% female) were cluster-randomized into either a control group or one of two intervention groups (M1 and M2). Two interventions based on different theoretical frameworks aimed to increase physical activity in school by approximately 120 min per week, throughout a 29-week intervention period. M1 consisted of 30 min physically active learning, 30 min physical activity and one 60 min physical education lesson. M2 consisted of one physical education lesson and one physical activity lesson, both focusing on facilitating students’ interest, responsibility and social relationships. The self-report version of the Strengths and Difficulties Questionnaire was used to assess mental health. Physical activity was measured by accelerometry. Linear mixed effects models were used to examine the effects of the interventions. Results No effects were found for the overall study population. Interaction effects warranted subgroup analyses: M1 showed favorable results in the subgroup with the highest levels of psychological difficulties at baseline (b = −2.9; −5.73 to −0.07; p = .045) and in the immigrant subgroup (b = −1.6; −3.53 to 0.27; p = .093). M2 showed favorable results in the immigrant subgroup (b = −2.1; −4.36 to 0.21; p = .075). Conclusions The two interventions did not improve mental health in the full study population. However, results indicated beneficial effects among immigrants and those with poor mental health at baseline. More research is needed due to missing values and the results should therefore be interpreted with caution.publishedVersio

The process evaluation of a school-based physical activity intervention: influencing factors and potential consequences of implementation

Purpose This paper evaluates the implementation of a school-based physical activity intervention and discusses how the intervention outcomes can be influenced by the implementation. Design/methodology/approach In four of the nine lower secondary schools in which the intervention was conducted, the authors examined implementation fidelity, adaptation, quality, responsiveness and dose received. The authors conducted focus group interviews with teachers (n = 8) and students (n = 46) and made observations. Dose delivered was examined quantitatively, with weekly registrations. Findings Results showed that two out of four schools made few and positive adaptations, implemented the intervention with high fidelity and quality and responded positively. Four main factors were found to influence implementation: frame factors, intervention characteristics, participant characteristics and provider characteristics. Research limitations/implications A cross-sectional design was used and may not represent implementation throughout the whole school year. Practical implications In terms of large-scale implementation, the intervention may be generalizable. However, intervention criteria such as adequate facilities and a flexible timetable may be unattainable for some schools. The intervention can be adapted without compromising its purpose, but adaptations should be a result of cooperation between students and teachers. Originality/value Process evaluations on this topic are rare. This study adds to a limited knowledge base concerning what factors may influence implementation of school-based physical activity interventions for adolescents.publishedVersio

School-based physical activity interventions, physical fitness and mental health among adolescents: Effects, associations and lessons learned from the School in Motion study

This thesis is part of the School in Motion study. School in Motion was initiated by the Norwegian government because of the political demand for more knowledge regarding possible approaches to increase adolescent physical activity. The reason for the demand was a report depicting 15-year-olds as among the most sedentary populations in Norway. This is concerning because physical activity can have a preventive function against non-communicable diseases, psychological difficulties and mental disorders. Norwegian schools are given extended responsibilities for their students’ physical and mental health. Physical activity can contribute in this purpose, therefore, finding feasible approaches to increase physical activity in school is an important research topic. The School in Motion study was a cluster randomized controlled trial involving 29 lower secondary schools in Norway. The participants were 2084 9th graders (14-15 years old) from schools located in western, south western, southern, and eastern parts of the country. The study aimed to implement two separate intervention models for increased physical activity and physical education in school, in order to evaluate their effects on physical activity, physical health, mental health, learning and learning environment. Intervention model 1 included weekly, 30 minutes of physical activity, 30 minutes of physically active academic lessons, and one additional physical education lesson. Intervention model 2 included two weekly physical activity lessons in which students were encouraged to pursue their own activity interests, in groups they formed themselves. The aims of this thesis were to elucidate different aspects of the relationship between school-based physical activity interventions, physical fitness and mental health among adolescents, and the feasibility of school-based PA interventions in lower secondary school. The data that are presented in this thesis are the basis of four separate papers. The first paper analyzed baseline data to examine the cross-sectional association between physical fitness and mental health. The results showed a small, inverse association between cardiorespiratory fitness and mental health, while no association was found between mental health and body composition or muscular strength. The second paper presents data from a qualitative study that aimed to elucidate how intervention model 2 was implemented, and what influenced the implementation. The results showed large differences in how the intervention was implemented. Specifically, two out of four investigated schools implemented the intervention adequately, one school implemented the intervention partially adequate and the last school failed at several implementation aspects. Four main factors were responsible for influencing implementation: frame factors, intervention-, participant-, and provider characteristics. The results elucidate the challenge of implementing a complex physical activity intervention in schools, i. e., complex contexts, and expecting the implementation process to be similar for the schools. The third paper examined the effect the interventions had on mental health, by using a cluster randomized controlled trial design. The results showed no intervention effects on the overall population. However, subgroup analyses indicated that intervention model 1 was beneficial for those with high levels of psychological difficulties at baseline, and both intervention models were beneficial for the immigrant subgroup. The results also indicated that intervention model 2 had a negative effect on a subscale of psychological difficulties, peer relationships, within the subgroups non-immigrant girls, and those with “borderline” psychological difficulties at baseline. The fourth paper presents associations between the one-year change in physical fitness components and mental health status. Subgroup analyses showed an inverse association between change in cardiorespiratory fitness and mental health status among boys; an inverse association between change in muscular strength and mental health status among immigrants; and an association between change in cardiorespiratory fitness and mental health among girls with high socioeconomic status. The results indicate that the associations between physical activity, physical fitness and mental health among adolescents depend on different mechanisms that are specific to certain subgroups. The findings of this thesis add nuance to a research field characterized by relatively few studies, small sample sizes, cross-sectional designs and little qualitative knowledge. In summary, this thesis suggests that improving cardiorespiratory fitness can be beneficial for mental health promotion among adolescent boys; and that improving muscular strength can be beneficial for mental health promotion among adolescent immigrants. Moreover, school-based PA programs can be useful for mental health promotion among adolescents with high levels of psychological difficulties and among adolescent immigrants. Regarding the implementation of physical activity programs in schools, this is feasible. However, a successful implementation depends to a large degree on schools’ facilities and frame factors, thus, the physical activity programs should have flexible designs to secure an optimal fit in each individual school. The new Core curriculum in Norway for primary and secondary education specifies that physical and mental health is to be an important interdisciplinary topic in school. The knowledge generated through this thesis can contribute to the development of this interdisciplinary topic, and to the ongoing discussion about the role of physical activity and mental health in school

Associations between changes in physical fitness and psychological difficulties status among Norwegian adolescents

Objectives To investigate the associations for one-year changes in cardiorespiratory fitness, muscular strength and body mass index, with psychological difficulties status in adolescents. Methods Norwegian 14-15-year-olds (n = 925) participated in data collection at two time points separated by one year. Psychological difficulties were assessed via the Strengths and Difficulties questionnaire and data from follow-up serve as the dependent variable. Cardiorespiratory fitness (the Andersen-test), muscular strength (Eurofit) and body mass index were measured. Change scores were calculated from the physical fitness variables and serve as independent variables in linear mixed effects models. Results There was no association between change in body mass index and psychological difficulties. Sex and socioeconomic status moderated the association between cardiorespiratory fitness and psychological difficulties. Immigrant status moderated the association between muscular strength and psychological difficulties. Subgroup results indicated inverse associations between change in cardiorespiratory fitness and psychological difficulties among boys (b = −0.009; 95% CI = −0.015 to −0.003; p = .006); change in muscular strength and psychological difficulties among immigrants (b = −1.97; 95% CI = −4.03 to 0.09; p = .061). Subgroup results also indicated an association between change in cardiorespiratory fitness and psychological difficulties among girls in the highest socioeconomic group (b = 0.014; 95% CI = 0.003 to 0.025; p = .014). Conclusions The associations for different fitness components were dependent on different moderators. Possibly, this indicates that associations in different subgroups are mediated by different mechanisms. Moderated associations should be addressed in future investigations.publishedVersio

The association between physical fitness and mental health in Norwegian adolescents

Background Studies indicate that health-related components of physical fitness are associated with mental health outcomes. However, research is scarce concerning this relationship in young adolescents in general and non-existent in Norwegian populations specifically. The aim of the study was to examine whether body composition, muscular strength and cardiorespiratory fitness were associated with self-reported mental health in Norwegian adolescents. Methods Adolescents from four regions of Norway (n = 1486; mean age = 13.9; girls = 50.6%) participated. Self-reported mental health (psychological difficulties) was measured by completing the Strengths and Difficulties Questionnaire. Cardiorespiratory fitness was assessed with an intermittent running test; muscular strength was assessed by measuring handgrip strength, standing broad jump and sit-ups; and body composition was assessed by calculating body mass index from weight and height. Linear mixed effects models were conducted to assess the associations between the health-related components of physical fitness and psychological difficulties. School clusters were included as random effects and all models were controlled for sex, socioeconomic status and birthplace (domestic or foreign). Results Body composition was not associated with psychological difficulties. Muscular strength was independently associated with psychological difficulties, but when all independent variables were entered in the fully adjusted model, only cardiorespiratory fitness was associated with psychological difficulties. Conclusions There was a small but significant inverse association between cardiorespiratory fitness and levels of psychological difficulties in Norwegian adolescents. The results suggest that muscular strength is not associated with psychological difficulties in adolescents, when controlling for cardiorespiratory fitness. Future research should focus on the prospective association between physical fitness components and mental health outcomes in adolescents.publishedVersio

Innovative use of ECC (NEC3) for procurement and management of infrastructure projects with limited funding: Bervie Braes case study

Purpose To investigate the effects of two school-based physical activity interventions on mental health in Norwegian adolescents. Methods Students from 29 lower secondary schools in Norway (n = 2084; 14–15 years; 49% female) were cluster-randomized into either a control group or one of two intervention groups (M1 and M2). Two interventions based on different theoretical frameworks aimed to increase physical activity in school by approximately 120 min per week, throughout a 29-week intervention period. M1 consisted of 30 min physically active learning, 30 min physical activity and one 60 min physical education lesson. M2 consisted of one physical education lesson and one physical activity lesson, both focusing on facilitating students’ interest, responsibility and social relationships. The self-report version of the Strengths and Difficulties Questionnaire was used to assess mental health. Physical activity was measured by accelerometry. Linear mixed effects models were used to examine the effects of the interventions. Results No effects were found for the overall study population. Interaction effects warranted subgroup analyses: M1 showed favorable results in the subgroup with the highest levels of psychological difficulties at baseline (b = −2.9; −5.73 to −0.07; p = .045) and in the immigrant subgroup (b = −1.6; −3.53 to 0.27; p = .093). M2 showed favorable results in the immigrant subgroup (b = −2.1; −4.36 to 0.21; p = .075). Conclusions The two interventions did not improve mental health in the full study population. However, results indicated beneficial effects among immigrants and those with poor mental health at baseline. More research is needed due to missing values and the results should therefore be interpreted with caution

The process evaluation of a school-based physical activity intervention: influencing factors and potential consequences of implementation

Purpose This paper evaluates the implementation of a school-based physical activity intervention and discusses how the intervention outcomes can be influenced by the implementation. Design/methodology/approach In four of the nine lower secondary schools in which the intervention was conducted, the authors examined implementation fidelity, adaptation, quality, responsiveness and dose received. The authors conducted focus group interviews with teachers (n = 8) and students (n = 46) and made observations. Dose delivered was examined quantitatively, with weekly registrations. Findings Results showed that two out of four schools made few and positive adaptations, implemented the intervention with high fidelity and quality and responded positively. Four main factors were found to influence implementation: frame factors, intervention characteristics, participant characteristics and provider characteristics. Research limitations/implications A cross-sectional design was used and may not represent implementation throughout the whole school year. Practical implications In terms of large-scale implementation, the intervention may be generalizable. However, intervention criteria such as adequate facilities and a flexible timetable may be unattainable for some schools. The intervention can be adapted without compromising its purpose, but adaptations should be a result of cooperation between students and teachers. Originality/value Process evaluations on this topic are rare. This study adds to a limited knowledge base concerning what factors may influence implementation of school-based physical activity interventions for adolescents

Effects of a school-based physical activity intervention on academic performance in 14-year old adolescents: a cluster randomized controlled trial – the School in Motion study

Background School-based physical activity interventions evaluating the effect on academic performance usually includes children. We aimed to investigate the effect of a nine-month, school-based physical activity intervention titled School in Motion (ScIM) on academic performance in adolescents. Methods Thirty secondary schools in Norway were cluster-randomized into three groups: the Physically active learning (PAL) group (n = 10), the Don’t worry – Be Happy (DWBH) group (n = 10) or control (n = 10). Target dose in both intervention groups was 120 min/week of additional PA during school hours. Parental consent was obtained from 2084 adolescent students (76%). Standardized national tests in reading and numeracy was conducted at baseline and at the end of the intervention. We used linear mixed model to test intervention effects. We found significant intervention effects in numeracy and reading among students in both interventions when compared with controls. Results The mean difference in change in numeracy was 1.7 (95% CI: 0.9 to 2.5; Cohen’s d = 0.12) and 2.0 (95% CI: 1.4 to 2.7; Cohen’s d = 0.23) points in favour of students in the PAL and DWBH intervention, respectively. Similar results were found for reading, where the mean difference in change was 0.9 (95% CI 0.2 to 1.6; Cohen’s d = 0.06) and 1.1 (95% CI 0.3 to 1.9; Cohen’s d = 0.18) points in favour of students in the PAL and DWBH intervention, respectively. When conducting intention to treat analysis with imputed data the estimates were attenuated and some no longer significant. Conclusion The ScIM study demonstrates that two different school-based PA interventions providing approximately 120 min of additional PA weekly over nine months, significantly improved numeracy and reading performance in 14-year old students compared with controls. However, the results should be interpreted with caution as the effect sizes reported were very small or small and the estimates were attenuated when conducting intention to treat analysis. Despite this, our results are still positive and suggest that PA interventions are viable models to increase academic performance among adolescents