Implementation of Strategies to Increase Adolescents' Access to Fruit And Vegetables at School: Process Evaluation Findings from the Boost Study

Access to fruit and vegetables (FV) is associated with adolescents' FV consumption. However, little is known about implementation of strategies to increase access to FV at schools. We examined the implementation of two environmental components designed to increase access to FV at Danish schools. Methods: We used data from 20 intervention schools involved in the school-based multicomponent Boost trial targeting 13-year-olds' FV consumption. The environmental components at school included daily provision of free FV and promotion of a pleasant eating environment. Questionnaire data was collected by the end of the nine-month intervention period among 1,121 pupils (95%), from all school principals (n = 20) and half way through the intervention period and by the end of the intervention among 114 teachers (44%). The implementation of the components was examined descriptively using the following process evaluation measures; fidelity, dose delivered, dose received and reach. Schools with stable high implementation levels over time were characterised by context, intervention appreciation and implementation of other components. Results: For all process evaluation measures, the level of implementation varied by schools, classes and over time. Dose received: 45% of pupils (school range: 13-72%, class range: 7-77%) ate the provided FV daily; 68% of pupils (school range: 40-93%, class range: 24-100%) reported that time was allocated to eating FV in class. Reach: The intake of FV provided did not differ by SEP nor gender, but more girls and low SEP pupils enjoyed eating FV together. Dose delivered: The proportion of teachers offering FV at a daily basis decreased over time, while the proportion of teachers cutting up FV increased over time. Schools in which high proportions of teachers offered FV daily throughout the intervention period were characterized by being: small; having a low proportion of low SEP pupils; having a school food policy; high teacher-and pupil intervention appreciation; having fewer teachers who cut up FV; and having high implementation of educational components. Conclusions: The appliance of different approaches and levels of analyses to describe data provided comprehension and knowledge of the implementation process. This knowledge is crucial for the interpretation of intervention effect.TrygFondenCenter for Health Promotion and Disease Prevention Research in Underserved Population

Trends in high life satisfaction among adolescents in five Nordic countries 2002–2014

Life satisfaction is an important indicator when assessing positive mental health aspects in populations, including among adolescents. The aim of this study was to investigate trends over time in prevalence of high life satisfaction among adolescents from five Nordic countries: Denmark, Iceland, Finland, Norway and Sweden. We used data from four waves of the Health Behaviour in School-Aged Children study from 2002, 2006, 2010 and 2014 (n=109,847). HBSC is a school-based study examining social circumstances, health and health behaviour among 11-, 13- and 15-years olds every four years in many European and North American countries. The Cantril Ladder, an 11-step visual analogue scale, was used as the measure of life satisfaction, and was dichotomised into two groups: high life satisfaction (scoring 9 or 10 on the scale) and medium/low life satisfaction (scoring <9). Over the 12-year period studied, between 28.6 and 44.8% of adolescents in the five countries rated their life satisfaction as high. Relatively large changes in prevalence levels occurred at the country level over the period. Denmark and Finland showed a steady, significant decline in the prevalence of high life satisfaction over the years. Iceland showed the highest prevalence in 2010. Norway and Sweden showed similar development until 2010, followed by a clear increase for Norway and a sharp decline in adolescent high life satisfaction for Sweden up until 2014. In all countries, high life satisfaction was most prevalent in 11-year- olds and least prevalent in almost all surveys among 15-year-old girls.peerReviewe

School-related mediators in social inequalities in smoking: a comparative cross-sectional study of 20,399 adolescents

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to examine the associations between social inequalities and daily smoking among 13 and 15 year olds, and to determine the role of students' academic achievement and school satisfaction in these associations.</p> <p>Methods</p> <p>HBSC is an international study including adolescents from 32 countries in Europe, Israel, and North America. The present study was based on information from 20,399 adolescents from Denmark, Sweden, Norway, Finland and the United Kingdom. Data were analysed by regression models.</p> <p>Results</p> <p>The initial analyses showed significant inequality in daily smoking in all countries except for Sweden. When adjusted for the mediating role of academic achievement, estimates were attenuated, but remained significant in three countries.</p> <p>Conclusion</p> <p>The study found social inequality in daily smoking in Denmark, Sweden, Norway, Finland and United Kingdom, as well as inequalities in students' academic achievement and school satisfaction. The analyses also showed that above average academic achievement was associated with lower OR of smoking. Teachers and politicians may find this information useful, and allocate resources to give higher priority to a supportive environment in schools especially for children and adolescents in lower social groups. Subsequently this prioritisation might contribute to reducing smoking in this group.</p

Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part II: qualitative studies

<p>Abstract</p> <p>Background</p> <p>Large proportions of children do not fulfil the World Health Organization recommendation of eating at least 400 grams of fruit and vegetables (FV) per day. To promote an increased FV intake among children it is important to identify factors which influence their consumption. Both qualitative and quantitative studies are needed. Earlier reviews have analysed evidence from quantitative studies. The aim of this paper is to present a systematic review of qualitative studies of determinants of children's FV intake.</p> <p>Methods</p> <p>Relevant studies were identified by searching Anthropology Plus, Cinahl, CSA illumine, Embase, International Bibliography of the Social Sciences, Medline, PsycINFO, and Web of Science using combinations of synonyms for FV intake, children/adolescents and qualitative methods as search terms. The literature search was completed by December 1st 2010. Papers were included if they applied qualitative methods to investigate 6-18-year-olds' perceptions of factors influencing their FV consumption. Quantitative studies, review studies, studies reported in other languages than English, and non-peer reviewed or unpublished manuscripts were excluded. The papers were reviewed systematically using standardised templates for summary of papers, quality assessment, and synthesis of findings across papers.</p> <p>Results</p> <p>The review included 31 studies, mostly based on US populations and focus group discussions. The synthesis identified the following potential determinants for FV intake which supplement the quantitative knowledge base: Time costs; lack of taste guarantee; satiety value; appropriate time/occasions/settings for eating FV; sensory and physical aspects; variety, visibility, methods of preparation; access to unhealthy food; the symbolic value of food for image, gender identity and social interaction with peers; short term outcome expectancies.</p> <p>Conclusions</p> <p>The review highlights numerous potential determinants which have not been investigated thoroughly in quantitative studies. Future large scale quantitative studies should attempt to quantify the importance of these factors. Further, mechanisms behind gender, age and socioeconomic differences in FV consumption are proposed which should be tested quantitatively in order to better tailor interventions to vulnerable groups. Finally, the review provides input to the conceptualisation and measurements of concepts (i.e. peer influence, availability in schools) which may refine survey instruments and theoretical frameworks concerning eating behaviours.</p

Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part I: quantitative studies

BACKGROUND: In order to more effectively promote fruit and vegetable intake among children and adolescents, insight into determinants of intake is necessary. We conducted a review of the literature for potential determinants of fruit and vegetable intake in children and adolescents. METHODS: Papers were identified from Medline and PsycINFO by using all combinations of the search terms: "fruit(s) or vegetable(s)" and "children or adolescents". Quantitative research examining determinants of fruit and/or vegetable intake among children and adolescents aged 6–18 years were included. The selection and review process was conducted according to a four-step protocol resulting in information on country, population, design, methodology, theoretical basis, instrument used for measuring intake, statistical analysis, included independent variables, and effect sizes. RESULTS: Ninety-eight papers were included. A large number of potential determinants have been studied among children and adolescents. However, for many presumed determinants convincing evidence is lacking, mostly because of paucity of studies. The determinants best supported by evidence are: age, gender, socio-economic position, preferences, parental intake, and home availability/accessibility. Girls and younger children tend to have a higher or more frequent intake than boys and older children. Socio-economic position, preferences, parental intake, and home availability/accessibility are all consistently positively associated with intake. CONCLUSION: The determinants most consistently supported by evidence are gender, age, socio-economic position, preferences, parental intake and home availability/accessibility. There is a need for internationally comparative, longitudinal, theory-based and multi-level studies taking both personal and environmental factors into account. This paper is published as part of the special Pro Children series in the International Journal of Behavioral Nutrition and Physical Activity. Please see [] for the relevant editorial

Determinants of fruit and vegetable intake among 11-year-old schoolchildren in a country of traditionally low fruit and vegetable consumption

BACKGROUND: Fruit and vegetable consumption is traditionally low in Iceland. The results of the Pro Children cross-Europe survey showed that the consumption was lowest among children in Iceland. The aim of this study was to identify determinants of fruit and vegetable intake among 11-year-old schoolchildren in Iceland. METHODS: A cross-sectional survey was performed in Iceland in the autumn of 2003 as a part of the Pro Children cross-Europe survey. The survey was designed to provide information on actual consumption levels of vegetables and fruits by 11-year-old school children and to assess potential determinants of consumption patterns. A total of 1235 Icelandic children (89%) from 32 randomly chosen schools participated. Hierarchical regression analyses were performed to determine the explained variance of the children's fruit and vegetable intake. In these analyses socio-demographic background variables were entered as a first block, perceived physical-environmental variables as a second block, perceived socio-environmental variables as a third block and personal variables as a fourth block. RESULTS: 64% of the children ate fruit less than once a day, and 61% ate vegetables less than once a day. Respectively, 31% and 39% of the variance in children's fruit and vegetable intake was explained by the determinants studied. About 7% and 13% of the variance in fruit and vegetable intake was explained by the perceived physical-environmental determinants, mainly by availability at home. About 18% and 16% of the variance in fruit and vegetable intake was explained by the personal determinants. For both fruit and vegetable intake, the significant personal determinants were preferences, liking, knowledge of recommendations and self-efficacy. CONCLUSION: Interventions to increase fruit and vegetable intake among children should aim at both environmental factors such as greater availability of fruit and vegetables, and personal factors as self-efficacy and knowledge levels concerning nutrition

The Boost study: design of a school- and community-based randomised trial to promote fruit and vegetable consumption among teenagers

BACKGROUND: The aim of the Boost study was to produce a persistent increase in fruit and vegetable consumption among 13-year-olds. This paper describes the development, implementation and evaluation of a school-and community-based, multi-component intervention guided by theory, evidence, and best practice. METHODS/DESIGN: We used the Intervention Mapping protocol to guide the development of the intervention. Programme activities combined environmental and educational strategies and focused on increasing access to fruit and vegetables in three settings: School: Daily provision of free fruit and vegetables; a pleasant eating environment; classroom curricular activities; individually computer tailored messages; one-day-workshop for teachers. Families: school meeting; guided child-parent activities; newsletters. Local community: guided visits in grocery stores and local area as part of classroom curriculum; information sheets to sports-and youth clubs. The Boost study employed a cluster-randomised controlled study design and applied simple two-stage cluster sampling: A random sample of 10 municipalities followed by a random sample of 4 schools within each municipality (N = 40 schools). Schools were randomised into a total of 20 intervention-and 20 control schools. We included all year 7 pupils except those from school classes with special needs. Timeline: Baseline survey: August 2010. Delivery of intervention: September 2010-May 2011. First follow-up survey: May/June 2011. Second follow-up survey: May/June 2012. Primary outcome measures: Daily mean intake of fruit and vegetables and habitual fruit and vegetable intake measured by validated 24-hour recall-and food frequency questionnaires. Secondary outcome measures: determinants of fruit and vegetable intake, positive side-effects and unintended adverse effects. Implementation was monitored by thorough process evaluation. DISCUSSION: The baseline data file included 2,156 adolescents (95%). There was baseline equivalence between intervention-and control groups for sociodemographics, primary outcomes, and availability at home, school and sports-and youth clubs. Significantly larger proportions of pupils in the control group had parents born in Denmark. The study will provide insights into effective strategies to increase fruit and vegetable intake among teenagers. The study will gain knowledge on implementation processes, intervention effects in population subgroups with low intake, and opportunities for including local communities in interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11666034

Trends in excellent self-rated health among adolescents: A comparative Nordic study

Background: Excellent self-rated health (SRH) can be seen as an important component of positive health among adolescents. The aim of this paper is to examine time trends of excellent health among adolescents in five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) between 2002 and 2014, including differences between countries, gender and age. Methods: Nordic data from the Health Behaviour in School-aged Children (HBSC) survey (including 11-, 13- and 15-year-olds) from 2002 (n = 19,009), 2006 (n = 29,656), 2010 (n = 33,232) and 2014 (n = 31,540) were analysed by design-adjusted binomial logistic regression models. Results: The trend analysis of excellent SRH for Nordic adolescents indicates a small improvement between 2002 and 2006 but a stable trend in the following periods up until 2014. The time trends do, however, depend on the specific country. In general, a smaller proportion of girls compared to boys were found to rate their health as excellent. Over time, however, the proportion of boys rating their health as excellent decreased, while girls’ ratings improved. Conclusions: From a public health perspective, indications of a changing trend in adolescent health coinciding with the 2007–2008 global recession warrant further attention from researchers and policy-makers and should be closely monitored in the future.</p