Psychosocial mediators of change in physical activity in the Welsh national exercise referral scheme: secondary analysis of a randomised controlled trial

Objective: While an increasing number of randomised controlled trials report impacts of exercise referral schemes (ERS) on physical activity, few have investigated the mechanisms through which increases in physical activity are produced. This study examines whether a National Exercise Referral Scheme (NERS) in Wales is associated with improvements in autonomous motivation, self-efficacy and social support, and whether change in physical activity is mediated by change in these psychosocial processes.<p></p> Methods: A pragmatic randomised controlled trial of NERS across 12 LHBs in Wales. Questionnaires measured demographic data and physical activity at baseline. Participants (N = 2160) with depression, anxiety or CHD risk factors were referred by health professionals and randomly assigned to control or intervention. At six months psychological process measures were collected by questionnaire. At 12 months physical activity was assessed by 7 Day PAR telephone interview. Regressions tested intervention effects on psychosocial variables, physical activity before and after adjusting for mediators and socio demographic patterning.<p></p> Results: Significant intervention effects were found for autonomous motivation and social support for exercise at 6 months. No intervention effect was observed for self-efficacy. The data are consistent with a hypothesis of partial mediation of the intervention effect by autonomous motivation. Analysis of moderators showed significant improvements in relative autonomy in all subgroups. The greatest improvements in autonomous motivation were observed among patients who were least active at baseline.<p></p> Discussion: The present study offered key insights into psychosocial processes of change in an exercise referral scheme, with effects on physical activity mediated by autonomous motivation. Findings support the use of self-determination theory as a framework for ERS. Further research is required to explain socio-demographic patterning in responses to ERS, with changes in motivation occurring among all sub-groups of participants, though not always leading to higher adherence or behavioural change. This highlights the importance of socio-ecological approaches to developing and evaluating behaviour change interventions, which consider factors beyond the individual, including conditions in which improved motivation does or does not produce behavioural change

Health improvement and educational attainment in secondary schools: complementary or competing priorities? Exploratory analyses from the School Health Research Network in Wales

Background. Implementing health improvement is often perceived as diverting resource away from schools’ core business, reflecting an assumption of a “zero-sum game” between health and education. There is some evidence that health behaviors may affect young people’s educational outcomes. However, associations between implementation of school health improvement and educational outcomes remains underinvestigated. Methods. The study linked school-level data on free school meal (FSM) entitlement, educational outcomes, and school attendance, obtained from government websites, with data from the School Environment Questionnaire (SEQ) on health improvement activity collected in Wales (2015/2016). Spearman’s rank correlation coefficients and linear regression models tested the extent of association between health improvement activity and attendance and educational outcomes. Results. SEQ data were provided by 100/115 network schools (87%), of whom data on educational performance were obtained from 97. The percentage of pupils entitled to FSM predicted most of the between-school variance in achievement and attendance. Linear regression models demonstrated significant positive associations of all measures of health improvement activity with attainment at Key Stage (KS) 3, apart from mental health education in the curriculum and organizational commitment to health. Student and parent involvement in planning health activities were associated with improved school attendance. There were no significant associations between health improvement and KS4 attainment. Conclusion. Implementing health improvement activity does not have a detrimental effect on schools’ educational performance. There is tentative evidence of the reverse, with better educational outcomes in schools with more extensive health improvement policies and practices. Further research should investigate processes by which this occurs and variations by socioeconomic status

Testing the ‘zero-sum game’ hypothesis: An examination of school health policies and practices and inequalities in educational outcomes

Background There is recognition that health and education are intrinsically linked through, for example, WHO's Health Promoting Schools (HPS) framework. Nevertheless, promoting health via schools is seen by some as a zero-sum game—ie, schools have nothing to gain, and may experience detriments to the core business of academic attainment because of focusing resources on health. Crucially, there is a paucity of evidence around the impacts of health and wellbeing policy and practice on attainment, with recent Cochrane reviews highlighting this gap. This study explored the zero-sum game hypothesis among schools with varying levels of deprivation—ie, the role of health and wellbeing interventions in schools in reducing or widening socioeconomic inequality in educational attainment. Methods Wales-wide, school-level survey data on health policies and practices, reflective of the HPS framework, were captured in 2016 using the School Environment Questionnaire. Questionnaire data were linked with routinely collected data on academic attainment. Primary outcomes included attendance and attainment at Key stages 3 (children aged 12–14 years) and 4 (15–16). Interaction terms were fitted to test whether there was an interaction between free school meals, overall HPS activity, and outcomes. Linear regression models were constructed separately for schools with high uptake of free school meals (>15% of pupils) and low uptake (<15%), adjusting for confounders. Findings The final analyses included 48 schools with low uptake of free school meals and 49 with high uptake. Significant interactions were observed between free school meals and overall HPS activity for Key stage 3 attainment (β=0·28, 95% CI 0·09–0·47) and attendance (0·05, 0·02–0·09), reflecting an association between health improvement activities and education outcomes among high, but not low, free school meal schools. There was no significant interaction for Key stage 4 attainment (0·18, −0·22 to 0·57). Interpretation Our findings did not support the zero-sum game hypothesis; in fact, among more deprived schools, there was a tendency for better attendance and attainment at Key stage 3. Schools must equip students with the skills required for good physical and mental health and wellbeing in addition to academic and cognitive skills. The study included a large, nationally representative sample of secondary schools; however, the cross-sectional nature has implications for causality

Lessons learnt: Undertaking rapid reviews on public health and social measures during a global pandemic.

Public health and social measures (PHSM) have been central to the COVID-19 response. Consequently, there has been much pressure on decision-makers to make evidence-informed decisions and on researchers to synthesize the evidence regarding these measures. This article describes our experiences, responses and lessons learnt regarding key challenges when planning and conducting rapid reviews of PHSM during the COVID-19 pandemic. Stakeholder consultations and scoping reviews to obtain an overview of the evidence inform the scope of reviews that are policy-relevant and feasible. Multiple complementary reviews serve to examine the benefits and harms of PHSM across different populations and contexts. Conceiving reviews of effectiveness as adaptable living reviews helps to respond to evolving evidence needs and an expanding evidence base. An appropriately skilled review team and good planning, coordination and communication ensures smooth and rigorous processes and efficient use of resources. Scientific rigor, the practical implications of PHSM-related complexity and likely time savings should be carefully weighed in deciding on methodological shortcuts. Making the best possible use of modeling studies represents a particular challenge, and methods should be carefully chosen, piloted and implemented. Our experience raises questions regarding the nature of rapid reviews and regarding how different types of evidence should be considered in making decisions about PHSM during a global pandemic. We highlight the need for readily available protocols for conducting studies on the effectiveness, unintended consequences and implementation of PHSM in a timely manner, as well as the need for rapid review standards tailored to "rapid" versus "emergency" mode reviewing

Testing the 'zero-sum game' hypothesis: An examination of school health policy and practice and inequalities in educational outcomes

Background: There is recognition that health and education are intrinsically linked, through for example the World Health Organizations' Health Promoting Schools' (HPS) framework. Nevertheless, promoting health via schools is seen by some as a 'zero-sum game'; that is, schools have nothing to gain, and in fact may experience detriments to the core business of academic attainment as a result of focussing resources on health. Crucially, there is a paucity of evidence around the impacts of health and well-being policy and practice on attainment, with recent Cochrane reviews highlighting this gap. This study explored the 'zero-sum game' hypothesis among schools with varying levels of deprivation; that is, the role of health and wellbeing interventions in schools in reducing, or widening, socioeconomic inequality in educational attainment. Methods: Wales-wide, school-level survey data on health policies and practices, reflective of the HPS framework, were captured in 2016 using the School Environment Questionnaire (SEQ). SEQ data were linked with routinely collected data on academic attainment. Primary outcomes included attendance and attainment at Key Stages 3 and 4. Interaction terms were fitted to test whether there was an interaction between FSM,overall HPS activity, and outcomes. Linear regression models were constructed separately for high (>15% of pupils) and low (<15%) Free School Meal (FSM) schools, adjusting for confounders. Findings: The final analyses included 48 low and 49 high FSM secondary schools. Significant interactions were observed between FSM and overall HPS for KS3 attainment (b=0.28; 95% CI: 0.09, 0.47) and attendance(b=0.05; 95% CI: 0.02, 0.09), reflecting an association between health improvement activities and education outcomes among high, but not low FSM schools. There was no significant interaction for KS4 attainment (b=0.18; 95% CI: -0.22, 0.57).Interpretation: Our findings did not support the 'zero-sum game' hypothesis; in fact, among more deprived schools, there was a tendency for better attendance and attainment at Key Stage 3. Schools must equip students with the skills required for good physical, mental health and well-being in addition to academic and cognitive skills. The study included a large, nationally representative sample of secondary schools;however, the cross-sectional nature has implications for causality

E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales

AbstractBackground E-cigarettes are seen by some as offering harm reduction potential, where used effectively as smoking cessation devices. However, there is emerging international evidence of growing use among young people, amid concerns that this may increase tobacco uptake. Few UK studies examine the prevalence of e-cigarette use in non-smoking children or associations with intentions to smoke.Methods A cross-sectional survey of year 6 (10–11-year-old) children in Wales. Approximately 1500 children completed questions on e-cigarette use, parental and peer smoking, and intentions to smoke. Logistic regression analyses among never smoking children, adjusted for school-level clustering, examined associations of smoking norms with e-cigarette use, and of e-cigarette use with intentions to smoke tobacco within the next 2 years.Results Approximately 6% of year 6 children, including 5% of never smokers, reported having used an e-cigarette. By comparison to children whose parents neither smoked nor used e-cigarettes, children were most likely to have used an e-cigarette if parents used both tobacco and e-cigarettes (OR=3.40; 95% CI 1.73 to 6.69). Having used an e-cigarette was associated with intentions to smoke (OR=3.21; 95% CI 1.66 to 6.23). While few children reported that they would smoke in 2 years’ time, children who had used an e-cigarette were less likely to report that they definitely would not smoke tobacco in 2 years’ time and were more likely to say that they might.Conclusions E-cigarettes represent a new form of childhood experimentation with nicotine. Findings are consistent with a hypothesis that children use e-cigarettes to imitate parental and peer smoking behaviours, and that e-cigarette use is associated with weaker antismoking intentions

School, peer and family relationships and adolescent substance use, subjective wellbeing and mental health symptoms in Wales: a cross sectional study

Positive relationships with family, friends and school staff are consistently linked with health and wellbeing during adolescence, though fewer studies explore how these micro-systems interact to influence adolescent health. This study tests the independent and interacting roles of family, peer and school relationships in predicting substance use, subjective wellbeing and mental health symptoms among 11–16 year olds in Wales. It presents cross-sectional analyses of the 2013 Health Behaviour in School-aged Children survey, completed by 9055 young people aged 11–16 years. Multilevel logistic regression analyses are used to test associations of family communication, family support, relationships with school staff, school peer connectedness, and support from friends, with tobacco use, cannabis use, alcohol use, subjective wellbeing and mental health symptoms. Positive relationships with family and school staff were consistently associated with better outcomes. Support from friends was associated with higher use of all substances, while higher school peer connectedness was associated with better subjective wellbeing and mental health. Better relationships with school staff were most strongly associated with positive subjective wellbeing, and fewer mental health symptoms where pupils reported less family support. Support from friends was associated with higher cannabis use and worse mental health among pupils with lower family support. Relationships with family and school staff may be important in protecting young people against substance use, and improving wellbeing and mental health. Interventions focused on student-staff relationships may be important for young people with less family support. Interventions based on peer support should be mindful of potential harmful effects for pupils with less support from family

From Complex Interventions to Complex Systems: Using Social Network Analysis to Understand School Engagement with Health and Wellbeing

Challenges in changing school system functioning to orient them towards health are commonly underestimated. Understanding the social interactions of school staff from a complex systems perspective may provide valuable insight into how system dynamics may impede or facilitate the promotion of health and wellbeing. Ego social network analysis was employed with wellbeing leads within four diverse case study schools to identify variability in embeddedness of health and wellbeing roles. This variation, as well as the broader context, was then explored through semi-structured qualitative interviews with school staff and a Healthy Schools Coordinator, sampled from the wellbeing leads&#8217; ego-networks. Networks varied in terms of perceived importance and frequency of interactions, centrality, brokerage and cliques. Case study schools that showed higher engagement with health and wellbeing had highly organised, distributed leadership structures, dedicated wellbeing roles, senior leadership support and outside agencies embedded within school systems. Allocation of responsibility for wellbeing to a member of the senior leadership team alongside a distributed leadership approach may facilitate the reorientation of school systems towards health and wellbeing. Ego-network analysis to understand variance in complex school system starting points could be replicated on a larger scale and utilised to design complex interventions