The sustainability of public health interventions in schools: a systematic review

Background: The sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. If effective interventions discontinue, new practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? What are the barriers and facilitators affecting the sustainability of public health interventions in schools in high-income countries? Methods: Seven bibliographic databases and 15 websites were searched. References and citations of included studies were searched, and experts and authors were contacted to identify relevant studies. We included reports published from 1996 onwards. References were screened on title/abstract, and those included were screened on full report. We conducted data extraction and appraisal using an existing tool. Extracted data were qualitatively synthesised for common themes, using May's General Theory of Implementation (2013) as a conceptual framework. Results: Of the 9677 unique references identified through database searching and other search strategies, 24 studies of 18 interventions were included in the review. No interventions were sustained in their entirety; all had some components that were sustained by some schools or staff, bar one that was completely discontinued. No discernible relationship was found between evidence of effectiveness and sustainability. Key facilitators included commitment/support from senior leaders, staff observing a positive impact on students' engagement and wellbeing, and staff confidence in delivering health promotion and belief in its value. Important contextual barriers emerged: the norm of prioritising educational outcomes under time and resource constraints, insufficient funding/resources, staff turnover and a lack of ongoing training. Adaptation of the intervention to existing routines and changing contexts appeared to be part of the sustainability process. Conclusions: Existing evidence suggests that sustainability depends upon schools developing and retaining senior leaders and staff that are knowledgeable, skilled and motivated to continue delivering health promotion through ever-changing circumstances. Evidence of effectiveness did not appear to be an influential factor. However, methodologically stronger primary research, informed by theory, is needed. Trial registration: The review was registered on PROSPERO: CRD42017076320, Sep. 2017

Understanding the development of minimum unit pricing of alcohol in Scotland: A qualitative study of the policy process

Background: Minimum unit pricing of alcohol is a novel public health policy with the potential to improve population health and reduce health inequalities. Theories of the policy process may help to understand the development of policy innovation and in turn identify lessons for future public health research and practice. This study aims to explain minimum unit pricing’s development by taking a ‘multiple-lenses’ approach to understanding the policy process. In particular, we apply three perspectives of the policy process (Kingdon’s multiple streams, Punctuated-Equilibrium Theory, Multi-Level Governance) to understand how and why minimum unit pricing has developed in Scotland and describe implications for efforts to develop evidence-informed policymaking. Methods: Semi-structured interviews were conducted with policy actors (politicians, civil servants, academics, advocates, industry representatives) involved in the development of MUP (n = 36). Interviewees were asked about the policy process and the role of evidence in policy development. Data from two other sources (a review of policy documents and an analysis of evidence submission documents to the Scottish Parliament) were used for triangulation. Findings: The three perspectives provide complementary understandings of the policy process. Evidence has played an important role in presenting the policy issue of alcohol as a problem requiring action. Scotland-specific data and a change in the policy ‘image’ to a population-based problem contributed to making alcohol-related harms a priority for action. The limited powers of Scottish Government help explain the type of price intervention pursued while distinct aspects of the Scottish political climate favoured the pursuit of price-based interventions. Conclusions: Evidence has played a crucial but complex role in the development of an innovative policy. Utilising different political science theories helps explain different aspects of the policy process, with Multi-Level Governance particularly useful for highlighting important lessons for the future of public health policy

Using qualitative research to explore intervention mechanisms: findings from the trial of the Learning Together whole-school health intervention

Background: This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the ‘Learning Together’ whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs. / Methods: Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes. / Results: The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community. / Conclusions: Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change. / Trial registration: ISRCTN registry 10751359. Registered on 11 March 2014

Effects of a Whole-School Health Intervention on Clustered Adolescent Health Risks: Latent Transition Analysis of Data from the INCLUSIVE Trial

Whole-school interventions are a promising approach to preventing bullying and aggression while promoting broader health. The main analyses from a trial of the INCLUSIVE whole-school intervention reported reductions in bullying victimisation but not aggression and improved mental well-being. Latent transition analysis can examine how interventions ‘move’ people between classes defined by multiple outcomes over time. We examined at baseline what classes best defined individuals’ bullying, aggression and mental well-being and what effects did the intervention have on movement between classes over time? INCLUSIVE was a two-arm cluster-randomised trial with 20 high schools per arm, with 24-month and 36-month follow-ups. We estimated sequential latent class solutions on baseline data. We then estimated a latent transition model including baseline, 24-month and 36-month follow-up measurements. Our sample comprised 8179 students (4082 control, 4097 intervention arms). At baseline, classes were (1) bullying victims, (2) aggression perpetrators, (3) extreme perpetrators and (4) neither victims nor perpetrators. Control students who were extreme perpetrators were equally likely to stay in this class (27.0% probability) or move to aggression perpetrators (25.0% probability) at 24 months. In the intervention group, fewer extreme perpetrators students remained (5.4%), with more moving to aggression perpetrators (65.1%). More control than intervention extreme perpetrators moved to neither victims nor perpetrators (35.2% vs 17.8%). Between 24 and 36 months, more intervention students moved from aggression perpetrators to neither victims nor perpetrators than controls (30.1% vs 22.3%). Our findings suggest that the intervention had important effects in transitioning students to lower-risk classes

Sexually transmitted infection risk exposure among black and minority ethnic youth in northwest London: findings from a study translating a sexually transmitted infection risk-reduction intervention to the UK setting.

OBJECTIVES: Young black women are disproportionately affected by sexually transmitted infections (STI) in the UK, but effective interventions to address this are lacking. The Young Brent Project explored the nature and context of sexual risk-taking in young people to inform the translation of an effective clinic-based STI reduction intervention (Project SAFE) from the USA to the UK. METHODS: One-to-one in-depth interviews (n = 37) and group discussions (n = 10) were conducted among men and women aged 15-27 years from different ethnic backgrounds recruited from youth and genitourinary medicine clinic settings in Brent, London. The interviews explored the context within which STI-related risks were assessed, experienced and avoided, the skills needed to recognise risk and the barriers to behaviour change. RESULTS: Concurrent sexual partnerships, mismatched perceptions and expectations, and barriers to condom use contributed to STI risk exposure and difficulties in implementing risk-reduction strategies. Women attempted to achieve monogamy, but experienced complex and fluid sexual relationships. Low risk awareness, flawed partner risk assessments, negative perceptions of condoms and lack of control hindered condom use. Whereas men made conscious decisions, women experienced persuasion, deceit and difficulty in requesting condom use, particularly with older partners. CONCLUSIONS: Knowledge of STI and condom use skills is not enough to equip young people with the means to reduce STI risk. Interventions with young women need to place greater emphasis on: entering and maintaining healthy relationships; awareness of risks attached to different forms of concurrency and how concurrency arises; skills to redress power imbalances and building self-esteem

Dilemmas of school-based Relationships and Sexuality Education for and about consent

In 2018, reflecting in this journal on the arrival of the ‘age of consent’ into sexuality education, Jen Gilbert questioned what would happen to a concept drawn in part from legal contexts, but partly also driven by the passion of feminist activists, when it met the demands and logics – the learning outcomes and lesson plans – of the classroom. This article offers one response, drawing on qualitative data from two whole-school sexual health programmes, Positive Choices and Project Respect, piloted in secondary schools in England between 2017 and 2019. It describes how each addressed the issue of consent and focuses on specific ‘moments’ that illuminate some of the challenges of doing so for both staff and students. Our analyses aim to contribute to the practice of relationships and sexuality education in schools by helping educators to anticipate, understand and therefore better address the dilemmas that teaching for and about consent might encounter. We argue that these dilemmas relate both to broader (and gendered) ideas of consent and entitlement, and to issues specific to schools. However, we also argue that a more theorised account of the school enables us to identify the minor achievements that are nonetheless possible

Locating and testing the healthy context paradox: examples from the INCLUSIVE trial

BACKGROUND: The healthy context paradox, originally described with respect to school-level bullying interventions, refers to the generation of differences in mental wellbeing amongst those who continue to experience bullying even after interventions successfully reduce victimisation. Using data from the INCLUSIVE trial of restorative practice in schools, we relate this paradox to the need to theorise potential harms when developing interventions; formulate the healthy context paradox in a more general form defined by mediational relationships and cluster-level interventions; and propose two statistical models for testing the healthy context paradox informed by multilevel mediation methods, with relevance to structural and individual explanations for this paradox. METHODS: We estimated two multilevel mediation models with bullying victimisation as the mediator and mental wellbeing as the outcome: one with a school-level interaction between intervention assignment and the mediator; and one with a random slope component for the student-level mediator-outcome relationship predicted by school-level assignment. We relate each of these models to contextual or individual-level explanations for the healthy context paradox. RESULTS: Neither model suggested that the INCLUSIVE trial represented an example of the healthy context paradox. However, each model has different interpretations which relate to a multilevel understanding of the healthy context paradox. CONCLUSIONS: Greater exploration of intervention harms, especially when those accrue to population subgroups, is an essential step in better understanding how interventions work and for whom. Our proposed tests for the presence of a healthy context paradox provide the analytic tools to better understand how to support development and implementation of interventions that work for all groups in a population. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN10751359

Enhanced magnetoresistance by monoatomic roughness in epitaxial Fe/MgO/Fe tunnel junctions

Under the terms of the Creative Commons Attribution License 3.0 (CC-BY).-- et al.Interfacial effects on spin and symmetry filtering in single-crystal Fe(001)/MgO/Fe magnetic tunnel junctions are investigated with the insertion of a Fe monoatomic step at the bottom MgO interface. After annealing, the atomically flat bottom electrode is covered by a fractional part of a Fe monoatomic layer resulting in two-dimensional Fe islands that are separated for low coverages and percolated above around half a monolayer. The magnetotransport properties of the junctions are studied as a function of this Fe sublayer coverage that is varied from 0 to 1 monolayer. Surprisingly, the magnetoresistance ratio exhibits a maximum for a coverage around half a monolayer. Tunneling spectroscopy experiments performed at low temperature allow relating this result to the decrease of the contribution of the interfacial resonance state to the conductance of the junction.C.T. acknowledges the following projects: SPINCHAT (ANR-07-BLAN-341), POS CCE ID.574, code SMIS-CSNR 12467, and the Exploratory Research Project, “SPINTAIL” PN-II-ID-PCE-2012-4-0315, No. 23/29.08.2013.Peer Reviewe

Is positive school climate and adolescent mental health: Longitudinal study of young people in England

Background and objectives: Studies suggest that individual student-reported connection to school is associated with better mental health. However, there is less evidence for associations between schools’ overall school climate and the mental health of their students. This may reflect limitations in which mental health outcomes have been examined. We conducted a large longitudinal study in schools, hypothesising that we would find associations at both the student and school levels between student-reported positive school climate, and reduced student conduct and emotional problems and improved mental wellbeing. // Methods: We tracked students in 20 English secondary schools from near the end of the first year of secondary school (age 11/12) over 3 years using reliable measures of school climate and mental health. // Results: We found associations between student-level reports of positive school climate at baseline, and reduced conduct and emotional problems and better mental wellbeing at 3-year follow-up adjusting for various potential confounders. We also found some evidence of adjusted associations between baseline school-level measures of overall positive climate and better student mental health at follow-up. However, these student- and school-level associations reduced considerably when also adjusting for baseline mental health. // Conclusions: Our findings suggest that there are associations between school climate and student mental health at both the student and school level but these associations are complex and not necessarily causal