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The UK average survival rate from out of hospital cardiac arrest (OHCA) is 8.6%, which is significantly lower than in comparable countries where survival rates can exceed 20%. A cardiac arrest victim is two to four times more likely to survive OHCA with bystander cardiopulmonary resuscitation (CPR). Mandatory teaching of CPR in schools is an effective way, endorsed by the World Health Organization, to train the entire population and improve the bystander CPR rate. Despite this, as with other UK home nations, there is significant variation in provision of CPR training within schools in Wales. Virtual reality (VR) technology offers an accessible, immersive way to teach CPR skills to schoolchildren. Computer scientists at the University of Chester and the Welsh Ambulance Services NHS Trust developed Virtual Cardio Pulmonary Resuscitation (VCPR), which can be used to teach children CPR skills. There were three stages: identifying requirements and specifications; development of a prototype; and management—development of software, further funding and exploring opportunities for commercialisation.

Australia is facing a shortfall in the number of appropriately skilled ICT workers needed for Australia’s future workforce. One avenue to address this issue is for universities and stakeholders to conduct initiatives to attract prospective students to ICT courses, by building self-efficacy and positive attitudes towards ICT careers. Previous gender-focused interventions have reported immediate positive effects in female students’ attitudes and confidence towards IT. There have been, however, no longer-term measures of the longitudinal changes of both male and female students’ attitudes and self-efficacy towards IT from such interventions. This research sought to investigate and compare the longitudinal effects of three different levels of interventions for IT upon primary school-aged students’ attitudes and self-efficacy towards computer programming and their interest to pursue programming. Immediate positive effects were generated by each of these interventions, which is consistent with previous research. A major finding of this research was that these immediate positive effects fade out over the following two school terms. This effect is significant with respect to students’ interest in pursuing programming. This is a novel finding revealed by the longitudinal nature of this research project. Interest and self-efficacy behaved differently over time. While self-efficacy still incurred some fade-out over the two terms, the residual benefit after two school terms was that students’ enhancement in self-efficacy had been retained above their initial baseline measures. Findings also indicate that the interventions may have different effects based on gender.

Summary Background Bullying, aggression, and violence among children and young people are some of the most consequential public mental health problems. We tested the Learning Together intervention, which involved students in efforts to modify their school environment using restorative practice and by developing social and emotional skills. Methods We did a cluster randomised trial, with economic and process evaluations, of the Learning Together intervention compared with standard practice (controls) over 3 years in secondary schools in south-east England. Learning Together consisted of staff training in restorative practice; convening and facilitating a school action group; and a student social and emotional skills curriculum. Primary outcomes were self-reported experience of bullying victimisation (Gatehouse Bullying Scale; GBS) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime (ESYTC) school misbehaviour subscale) measured at 36 months. We analysed data using intention-to-treat longitudinal mixed-effects models. This trial was registered with the ISRCTN registry (10751359). Findings We included 40 schools (20 in each group); no schools withdrew. 6667 (93·6%) of 7121 students participated at baseline and 5960 (83·3%) of 7154 at 36 months. Mean GBS bullying score at 36 months was 0·34 (SE 0·02) in the control group versus 0·29 (SE 0·02) in the intervention group, with a significant adjusted mean difference (−0·03, 95% CI −0·06 to −0·001; adjusted effect size −0·08). Mean ESYTC score at 36 months was 4·33 (SE 0·20) in the control group versus 4·04 (0·21) in the intervention group, with no evidence of a difference between groups (adjusted difference −0·13, 95% CI −0·43 to 0·18; adjusted effect size −0·03). Costs were an additional £58 per pupil in intervention schools than in control schools. Interpretation Learning Together had small but significant effects on bullying, which could be important for public health, but no effect on aggression. Interventions to promote student health by modifying the whole-school environment are likely to be one of the most feasible and efficient ways of addressing closely related risk and health outcomes in children and young people. Funding National Institute for Health Research, Educational Endowment Foundation.

Background This study investigates how the sexual health outcomes of a representative sample of students aged 15–16 in Wales vary according to the person delivering Sex and Relationships Education (SRE) in schools, students’ access to on-site sexual health services and access to free condoms. Methods Cross-sectional, self-report survey data were collected from students who participated in the 2015/16 School Health Research Network questionnaire in Wales. Data were analyzed from 59 schools, totalling 3781 students aged 15–16 (M = 15.7; SD = 0.3) who responded to questions about ever having had sex; age of sexual initiation and condom use at last intercourse. School level data were also collected, examining who delivers school SRE, provision of on-site, school ‘drop-in’ sexual health services and provision of free condoms for students. Binary and linear multi-level analyses explored the relationship between school level predictors and sexual health outcomes. Results Compared to teachers, other modes of SRE delivery were associated with better sexual health outcomes, including remaining sexually inactive, later age of first intercourse and condom use. Providing on-site sexual health services did not significantly reduce the odds of having ever had sex or delaying first intercourse; but was associated with increased condom use. On-site condom provision was associated with lower condom use. Conclusions SRE delivery by educators other than teachers is optimum to young people’s sexual health outcomes. Further funding and coordination of on-site sexual health advice services are required. Longitudinal research is needed to identify the temporal sequence of sexual health practices and outcomes.

Background: Dating and relationship violence (DRV) is under-researched in the UK, especially among Further\ud Education (FE) students. This study examines the association between DRV victimisation and\ud sociodemographic characteristics, sexual identity and dating and relationship behaviours among 16-19 year-old\ud FE students.\ud Methods: Cross-sectional self-report data were collected from 1751 students aged 16-19 at six FE settings in\ud England and Wales. Factor analysis examined the structure of DRV victimisation by gender. Multilevel logistic\ud regression examined the odds ratios of DRV victimisation according to socio-demographics, sexual identity and\ud dating behaviours.\ud \ud Results: DRV victimisation clusters into two categories for females, and three for males. Among females,\ud 46.1% experienced controlling behaviours and 31.6% threatening behaviours; 49.9% of males experienced\ud controlling behaviours, 27.1% threatening behaviours and 5.8% online sexual violence. The odds of DRV\ud victimisation were 2-8 times greater for males and 2-4 times greater for females who had ever sent a sexually\ud explicit image. No consistent association was found between DRV and age, spending money per week,\ud educational attainment or meeting partners online.\ud Conclusions: The high prevalence, absence of gender differences and social patterning suggests DRV\ud victimisation may be becoming normalised and is of significant public health importance for young people in\ud England and Wales.

BackgroundIllicit drug use increases the risk of poor physical and mental health. There are few effective drug prevention interventions.ObjectiveTo assess the acceptability of implementing and trialling two school-based peer-led drug prevention interventions.DesignStage 1 – adapt ASSIST, an effective peer-led smoking prevention intervention to deliver information from the UK national drug education website [see www.talktofrank.com (accessed 29 August 2017)]. Stage 2 – deliver the two interventions, ASSIST + FRANK (+FRANK) and FRANK friends, examine implementation and refine content. Stage 3 – four-arm pilot cluster randomised control trial (cRCT) of +FRANK, FRANK friends, ASSIST and usual practice, including a process evaluation and an economic assessment.SettingFourteen secondary schools (two in stage 2) in South Wales, UK.ParticipantsUK Year 8 students aged 12–13 years at baseline.Interventions+FRANK is a UK informal peer-led smoking prevention intervention provided in Year 8 followed by a drug prevention adjunct provided in Year 9. FRANK friends is a standalone informal peer-led drug prevention intervention provided in Year 9. These interventions are designed to prevent illicit drug use through training influential students to disseminate information on the risks associated with drugs and minimising harms using content from www.talktofrank.com. Training is provided off site and follow-up visits are made in school.OutcomesStage 1 – +FRANK and FRANK friends intervention manuals and resources. Stage 2 – information on the acceptability and fidelity of delivery of the interventions for refining manuals and resources. Stage 3 – (a) acceptability of the interventions according to prespecified criteria; (b) qualitative data from students, staff, parents and intervention teams on implementation and receipt of the interventions; (c) comparison of the interventions; and (d) recruitment and retention rates, completeness of primary, secondary and intermediate outcome measures and estimation of costs.Results+FRANK and FRANK friends were developed with stakeholders [young people, teachers (school management team and other roles), parents, ASSIST trainers, drug agency staff and a public health commissioner] over an 18-month period. In the stage 2 delivery of +FRANK, 12 out of the 14 peer supporters attended the in-person follow-ups but only one completed the electronic follow-ups. In the pilot cRCT, 12 schools were recruited, randomised and retained. The student response rate at the 18-month follow-up was 93% (1460/1567 students). Over 80% of peer supporters invited were trained and reported conversations on drug use and contact with trainers. +FRANK was perceived less positively than FRANK friends. The prevalence of lifetime illicit drug use was 4.1% at baseline and 11.6% at follow-up, with low numbers of missing data for all outcomes. The estimated cost per school was £1942 for +FRANK and £3041 for FRANK friends. All progression criteria were met.ConclusionsBoth interventions were acceptable to students, teachers and parents, but FRANK friends was preferred to +FRANK. A limitation of the study was that qualitative data were collected on a self-selecting sample. Future work recommendations include progression to a Phase III effectiveness trial of FRANK friends.Trial registrationCurrent Controlled Trials ISRCTN14415936.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 7. See the NIHR Journals Library website for further project information. The work was undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer). Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK CRC, is gratefully acknowledged.

BackgroundBullying, aggression and violence among children and young people are some of the most consequential public mental health problems.ObjectivesThe INCLUSIVE (initiating change locally in bullying and aggression through the school environment) trial evaluated the Learning Together intervention, which involved students in efforts to modify their school environment using restorative approaches and to develop social and emotional skills. We hypothesised that in schools receiving Learning Together there would be lower rates of self-reported bullying and perpetration of aggression and improved student biopsychosocial health at follow-up than in control schools.DesignINCLUSIVE was a cluster randomised trial with integral economic and process evaluations.SettingForty secondary schools in south-east England took part. Schools were randomly assigned to implement the Learning Together intervention over 3 years or to continue standard practice (controls).ParticipantsA total of 6667 (93.6%) students participated at baseline and 5960 (83.3%) students participated at final follow-up. No schools withdrew from the study.InterventionSchools were provided with (1) a social and emotional curriculum, (2) all-staff training in restorative approaches, (3) an external facilitator to help convene an action group to revise rules and policies and to oversee intervention delivery and (4) information on local needs to inform decisions.Main outcome measuresSelf-reported experience of bullying victimisation (Gatehouse Bullying Scale) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale) measured at 36 months. Intention-to-treat analysis using longitudinal mixed-effects models.ResultsPrimary outcomes – Gatehouse Bullying Scale scores were significantly lower among intervention schools than among control schools at 36 months (adjusted mean difference –0.03, 95% confidence interval –0.06 to 0.00). There was no evidence of a difference in Edinburgh Study of Youth Transitions and Crime scores. Secondary outcomes – students in intervention schools had higher quality of life (adjusted mean difference 1.44, 95% confidence interval 0.07 to 2.17) and psychological well-being scores (adjusted mean difference 0.33, 95% confidence interval 0.00 to 0.66), lower psychological total difficulties (Strengths and Difficulties Questionnaire) score (adjusted mean difference –0.54, 95% confidence interval –0.83 to –0.25), and lower odds of having smoked (odds ratio 0.58, 95% confidence interval 0.43 to 0.80), drunk alcohol (odds ratio 0.72, 95% confidence interval 0.56 to 0.92), been offered or tried illicit drugs (odds ratio 0.51, 95% confidence interval 0.36 to 0.73) and been in contact with police in the previous 12 months (odds ratio 0.74, 95% confidence interval 0.56 to 0.97). The total numbers of reported serious adverse events were similar in each arm. There were no changes for staff outcomes. Process evaluation – fidelity was variable, with a reduction in year 3. Over half of the staff were aware that the school was taking steps to reduce bullying and aggression. Economic evaluation – mean (standard deviation) total education sector-related costs were £116 (£47) per pupil in the control arm compared with £163 (£69) in the intervention arm over the first two facilitated years, and £63 (£33) and £74 (£37) per pupil, respectively, in the final, unfacilitated, year. Overall, the intervention was associated with higher costs, but the mean gain in students’ health-related quality of life was slightly higher in the intervention arm. The incremental cost per quality-adjusted life year was £13,284 (95% confidence interval –£32,175 to £58,743) and £1875 (95% confidence interval –£12,945 to £16,695) at 2 and 3 years, respectively.LimitationsOur trial was carried out in urban and periurban settings in the counties around London. The large number of secondary outcomes investigated necessitated multiple statistical testing. Fidelity of implementation of Learning Together was variable.ConclusionsLearning Together is effective across a very broad range of key public health targets for adolescents.Future workFurther studies are required to assess refined versions of this intervention in other settings.Trial registrationCurrent Controlled Trials ISRCTN10751359.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 18. See the NIHR Journals Library website for further project information. Additional funding was provided by the Educational Endowment Foundation.

Background Schools struggle to timetable health education. Interventions integrating academic and health education to reduce substance use and violence offer promise. No current systematic reviews examine such interventions. Objectives To review evidence to explore the following questions: (1) what types of interventions integrating health and academic education in schools serving those aged 4–18 years have been evaluated? (2) What theories of change inform these interventions? (3) What factors facilitate or limit the successful implementation and receipt of such interventions, and what are the implications for the delivery of such implementations in the UK? (4) How effective are such interventions in reducing smoking and violence and the use of alcohol and drugs, and at increasing attainment? Does this vary by students’ sociodemographic characteristics? (5) What factors appear to influence the effectiveness of such interventions? Data sources In total, 19 databases were searched from 18 November to 22 December 2015, updating searches for outcome evaluations for violence on 28 February 2018 and for substance use on 14 May 2018. References were extracted from included studies and authors contacted. Review methods Included studies reported on theories of change, and process or outcome evaluations of interventions that integrated academic and health education to reduce substance use and/or violence. References were screened on the title/abstract and then on the full report. Data extraction and appraisal used Cochrane, Evidence for Policy and Practice Information Centre and other established tools. Theories of change and process data were qualitatively synthesised. Outcome evaluations were synthesised narratively and meta-analytically. Results In total, 78,451 unique references were originally identified and 62 reports included. Search updates on 28 February and 14 May 2018 retrieved a further 2355 and 1945 references, respectively, resulting in the inclusion of six additional reports. Thirty-nine reports described theories, 16 reports (15 studies) evaluated process and 41 reports (16 studies) evaluated outcomes. Multicomponent interventions are theorised to erode ‘boundaries’ (strengthen relationships) between academic and health education, teachers and students, behaviour in classrooms and in the wider school, and schools and families. Teachers, pro-social peers and parents are theorised to act as role models and reinforcers of healthy behaviours learnt in lessons. There was clear evidence that interventions are facilitated by supportive senior management and alignment with the schools’ ethos, collaborative and supportive teaching environments, and positive pre-existing student, teacher and parent attitudes towards interventions. The barriers were overburdened teachers who had little time to both learn and implement integrated curricula. The strongest evidence for effectiveness was found for the reduction of substance use in school key stages (KSs) 2 and 3. For example, a meta-analysis for substance use at KS3 reported a mean difference of –0.09 (95% confidence interval –0.17 to –0.01). A meta-analysis for effectiveness in reducing violence victimisation in KS2 found no effect. There was mixed evidence for effects on academic outcomes, with meta-analysis precluded by methodological heterogeneity. Limitations Study quality was variable. Integration was sometimes not emphasised in theories of change. Conclusions These interventions are undertheorised but involve multiple forms of boundary erosion. There is clear evidence of characteristics affecting implementation. Interventions are likely to have the greatest impact on substance use. These programmes may be effective in reducing substance use but do not appear to reduce violence and findings on educational impacts are mixed. Future work Future evaluations should assess interventions with clearer theories of change and examine academic outcomes alongside violence and substance use outcomes. Study registration This study is registered as PROSPERO CRD42015026464. Funding The National Institute for Health Research Public Health Research programme.

Evidence that health and education are interlinked is transforming investment in adolescent health. However, no comprehensive theory of how schools influence mental and physical health, which could guide, and be tested through, empirical studies, exists. Using neuroscience, sociology, and other disciplines, we theorise that schools catering for students age 11-18 years can influence health by affecting the behavioural roles that are available for students to perform, the resources available to influence student behaviour, and how peers and teachers (known as the audience) respond. Some schools offer opportunities for students to adopt diverse pro-school roles and to maintain these roles via constructive feedback. Other schools focus narrowly on high academic attainment. Where pro-school roles are unavailable, are beyond students' resources, or elicit negative responses from teachers and peers, students might experience anxiety and choose to adopt anti-school roles, particularly in later adolescence. Behaviours that harm health, such as violence and drug use, are central to anti-school roles because they can facilitate belonging and status within anti-school peer groups and symbolise alternative transitions to adulthood.

Purpose– Evaluation of the Teens & Toddlers (T & T) positive youth development (PYD) and teenage pregnancy prevention programme suggested that the intervention had minimal effectiveness partly due to its unclear theory of change. The purpose of this paper is to examine the lived experiences of young women participating in the programme to contribute to a clearer understanding of intervention process and potential mechanisms.Design/methodology/approach– The authors conducted four focus groups (n=20), eight paired or triad interviews (n=12) and 15 interviews with young women participating in an randomized controlled trial of the T & T programme in England, analysing these data using a phenomenological approach.Findings– T & T provided some opportunities to experience the “five Cs” that underpin PYD programme theory: competence, confidence, connection, character and caring. However, the young women did not experience the programme in a way that would consistently develop these characteristics. The lack of opportunities for skill-building and challenge in the activities constrained their ability to build competence and confidence. Some programme facilitators and counsellors were able to achieve connections and caring relationships with the young women, though other adults involved in the programme were sometimes perceived by the participants as overly critical. The character development activities undertaken in the programme addressed attitudes towards sexual risk-taking.Originality/value– Few studies of the PYD approach examine young people’s perspectives. This research suggests that the young women were not consistently provided with opportunities to achieve youth development within the T & T programmes. In refining the programme, more thought is needed regarding how delivery of particular components may facilitate or impede a PYD experience.

The theory of human functioning and school organisation informed by Basil Bernstein?s sociology of education suggests that to gain the commitment and promote the health of students, particularly those from disadvantaged backgrounds, schools require radical transformations eroding various ?boundaries?: between and among staff and students; between students? academic learning and broader social development and welfare; and between schools and their local communities. Existing research examining this theory has reported associations between school-level proxy measures of student commitment and lower rates of student smoking, drinking alcohol, use of drugs and violence. But this research has not directly assessed whether reduced school boundaries explain this. We piloted a new scale derived from teacher reports to measure unhealthy school boundaries and examined its inter-item reliability and its criterion validity in terms of associations with various measures of school commitment and smoking. Data on boundaries came from 101 teachers across 40 schools. Data on student commitment and smoking came from 6667 students. We assessed reliability by examining correlations between scale-items and criterion validity in terms of associations with student-reported commitment and smoking. Inter-item reliability was sub-optimal but better within the subscales about boundaries between academic/broader learning and schools/local communities. The scale had good criterion validity, strongly associated with reduced student-reported school commitment and increased student-reported smoking. We reflect on the implications of these findings in terms of critical perspectives on health promotion in schools and the strengths and limitations of quantitative research in examining health behaviours as opposed to practices.

Introduction Teenage pregnancy remains a worldwide health concern which is an outcome of, and contributor to, health inequalities. The need for gender-aware interventions with a focus on males in addressing teenage pregnancy has been highlighted as a global health need by WHO and identified in systematic reviews of (relationship and sexuality education (RSE)). This study aims to test the effectiveness of an interactive film-based RSE intervention, which draws explicit attention to the role of males in preventing an unintended pregnancy by reducing unprotected heterosexual teenage sex among males and females under age 16 years. Methods and analysis A phase III cluster randomised trial with embedded process and economic evaluations. If I Were Jack encompasses a culturally sensitive interactive film, classroom materials, a teacher-trainer session and parent animations and will be delivered to replace some of the usual RSE for the target age group in schools in the intervention group. Schools in the control group will not receive the intervention and will continue with usual RSE. Participants will not be blinded to allocation. Schools are the unit of randomisation stratified per country and socioeconomic status. We aim to recruit 66 UK schools (24 in Northern Ireland; 14 in each of England, Scotland and Wales), including approximately 7900 pupils. A questionnaire will be administered at baseline and at 12–14 months postintervention. The primary outcome is reported unprotected sex, a surrogate measure associated with unintended teenage pregnancy. Secondary outcomes include knowledge, attitudes, skills and intentions relating to avoiding teenage pregnancy in addition to frequency of engagement in sexual intercourse, contraception use and diagnosis of sexually transmitted infections. Ethics and dissemination Ethical approval was obtained from Queen’s University Belfast. Results will be published in peer-reviewed journals and disseminated to stakeholders. Funding is from the National Institute for Health Research. Trial registration number ISRCTN99459996

Introduction Teenage pregnancy remains a worldwide health concern which is an outcome of, and contributor to, health inequalities. The need for gender-sensitive interventions with a focus on males in addressing teenage pregnancy has been highlighted as a global health need by the World Health Organisation and identified in systematic reviews of relationship and sexuality education (RSE). This study aims to test the effectiveness of an interactive film-based RSE intervention which draws explicit attention to the role of males in preventing an unintended pregnancy by reducing unprotected heterosexual teenage sex among males and females under age 16 years. Methods and analysis A Phase III effectiveness cluster randomised trial with embedded process and economic evaluations. If I Were Jack encompasses a culturally sensitive interactive film, classroom materials, a teacher-trainer session and parent animations, and will supplement usual RSE for the target age group in schools in the intervention group. Schools in the control group will not receive the intervention and will continue with usual RSE. Participants will not be blinded to allocation. Schools are the unit of randomisation stratified per country and socio-economic status. We aim to recruit 66 UK schools (24 in Northern Ireland; 14 in each of England, Scotland and Wales) and approximately 7900 pupils. A questionnaire will be administered at baseline and at 12-14 months post-intervention. The primary outcome is reported unprotected sex, a surrogate measure associated with unintended teenage pregnancy. Secondary outcomes include knowledge, attitudes, skills and intentions relating to avoiding teenage pregnancy in addition to frequency of engagement in sexual intercourse, contraception use, and diagnosis of sexually transmitted infections. Ethics and dissemination Ethical approval was obtained from Queen’s University Belfast. Results will be published in peer-reviewed journals and disseminated to stakeholders. Funding is from the National Institute for Health Research.Trial registration ISRCTN: 99459996; Pre-resultsSTRENGTHS AND LIMITATIONS OF THIS STUDY • The study is evaluating the first RSE intervention to be developed and trialled which explicitly promotes a gender-sensitive approach to addressing teenage pregnancy by focussing on male perspectives. • The intervention is culturally sensitive to different parts of the UK, non-directive in terms of pregnancy resolution options and sufficiently flexible to allow use within schools which vary in their personal development/RSE policy, including in faith-based schools.• It is the first RSE Intervention to be developed and trialled across all four nations of the UK, allowing for exploration of what works best where.• Due to the nature of the intervention and setting – within schools – participating teachers, pupils and parents cannot be blinded to allocation.• A biological measure of adolescent conception rates was not possible and hence we rely on a surrogate measure of incidence of unprotected sex.

Background Within increasingly constrained school timetables, interventions that integrate academic and health education to reduce substance use and violence may hold promise as a category of intervention that can positively affect both academic and health outcomes. There are no current systematic reviews exploring the effectiveness of such interventions or factors that affect their implementation. Methods A total of 19 bibliographic databases and 32 websites were searched. References were also extracted from the reference lists of included studies, and experts and authors were contacted to identify relevant studies. We included reports with no restrictions on language or date. References were screened on title/abstract and those not thus excluded were screened on full report. Data extraction and appraisal followed the Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Extracted process data were qualitatively meta-synthesised for common themes. Results Seventy-eight thousand four hundred fifty-one unique references were identified, and 62 reports were included. A total of 16 reports (reporting on 15 studies of 12 interventions) evaluated process. Key facilitators of integrated academic and health curricula were supportive senior management and alignment of the intervention with school ethos; a positive teaching environment, including positive perceptions around the ability to be flexible in the adaptation and delivery of integrated academic and health curricula; positive pre-existing student and teacher attitudes towards intervention content; and parental support of interventions, largely through reinforcement of messaging at home. Important barriers were over-burdened teachers, with little time to learn and implement integrated curricula. Conclusion Several useful facilitating and inhibiting factors linked to the implementation of interventions that integrate academic and health education for reduced substance use and/or violence were identified, providing tentative but insightful evidence of context-specific issues that may impact intervention success. However, overall, there is still a considerable gap in our understanding of how to achieve the successful implementation of these interventions. Electronic supplementary material The online version of this article (10.1186/s13643-018-0886-3) contains supplementary material, which is available to authorized users.

Purpose – The purpose of this paper is to explore the process of involving students and staff on school action groups, and staff and student experiences of reviewing local data and initiating school-level changes, to address bullying and other aggression. Design/methodology/approach – The authors draw on qualitative, process data collected at four purposively sampled pilot intervention schools in England via semi-structured interviews with school managers, action group members and facilitators (n=33), focus groups with students (n=16) and staff (n=4), and observations. Findings – School staff used multiple methods to recruit a diverse range of students onto school action groups. Locally tailored data reports were an important catalyst for action groups to identify priorities and plan whole school change – both through the process of “validation” (whereby existing concerns were confirmed) and “discovery” (whereby new problems were identified). An unexpected benefit of providing schools with these data was that it triggered analyses of other data sources, including routine monitoring data. External facilitators were important in promoting student voice and ensuring the intervention retained integrity as a whole-school restorative approach. Practical implications – It was feasible to involve young people using action groups, and there was evidence of school-level actions led by students, including in disadvantaged school contexts. Future Health Promoting Schools interventions could incorporate this approach to support locally appropriate, school-level change. Originality/value – The micro-level processes that were observed, whereby action groups interrogated feedback reports and collected additional data, suggest the responsiveness of such youth-involvement interventions to local needs. Contrary to many public health interventions, implementation appeared to be facilitated rather than hindered by features of the secondary-school “market” whereby parents have some choice between schools.

BackgroundIn contrast to curriculum-based health education interventions in schools, the school environment approach promotes health by modifying schools' physical/social environment. This systematic review reports on the health effects of the school environment and processes by which these might occur. It includes theories, intervention outcome and process evaluations, quantitative studies and qualitative studies.Research questionsResearch question (RQ)1: What theories are used to inform school environment interventions or explain school-level health influences? What testable hypotheses are suggested? RQ2: What are the effects on student health/inequalities of school environment interventions addressing organisation/management; teaching/pastoral care/discipline; and the physical environment? What are the costs? RQ3: How feasible/acceptable and context dependent are such interventions? RQ4: What are the effects on student health/inequalities of school-level measures of organisation/management; teaching/pastoral care/discipline; and the physical environment? RQ5: Through what processes might such influences occur?Data sourcesA total of 16 databases were searched between 30 July 2010 and 23 September 2010 to identify relevant studies, including the British Educational Index, the Cumulative Index to Nursing and Allied Health Literature, the Health Management Information Consortium, EMBASE, MEDLINE and PsycINFO. In addition, references of included studies were checked and authors contacted.Review methodsIn stage 1, we mapped references concerning how the school environment affects health and consulted stakeholders to identify stage 2 priorities. In stage 2, we undertook five reviews corresponding to our RQs.ResultsStage 1: A total of 82,775 references were retrieved and 1144 were descriptively mapped. Stage 2: A total of 24 theories were identified (RQ1). The human functioning and school organisation, social capital and social development theories were judged most useful. Ten outcome evaluations were included (RQ2). Four US randomised controlled trials (RCTs) and one UK quasi-experimental study examined interventions building school community/relationships. Studies reported benefits for some, but not all outcomes (e.g. aggression, conflict resolution, emotional health). Two US RCTs assessed interventions empowering students to contribute to modifying food/physical activity environments, reporting benefits for physical activity but not for diet. Three UK quasi-experimental evaluations examined playground improvements, reporting mixed findings, with benefits being greater for younger children and longer break times. Six process evaluations (RQ3) reported positively. One study suggested that implementation was facilitated when this built on existing ethos and when senior staff were supportive. We reviewed 42 multilevel studies, confining narrative synthesis to 10 that appropriately adjusted for confounders. Four UK/US reports suggested that schools with higher value-added attainment/attendance had lower rates of substance use and fighting. Three reports from different countries examined school policies on smoking/alcohol, with mixed results. One US study found that schools with more unobservable/unsupervised places reported increased substance use. Another US study reported that school size, age structure and staffing ratio did not correlate with student drinking. Twenty-one qualitative reports from different countries (RQ5) suggested that disengagement, lack of safety and lack of participation in decisions may predispose students to engage in health risks.LimitationsWe found no evidence regarding health inequalities or cost, and could not undertake meta-analysis.ConclusionsThere is non-definitive evidence for the feasibility and effectiveness of school environment interventions involving community/relationship building, empowering student participation in modifying schools' food/physical activity environments, and playground improvements. Multilevel studies suggest that schools that add value educationally may promote student health. Qualitative studies suggest pathways underlying these effects. This evidence lends broad support to theories of social development, social capital and human functioning and school organisation. Further trials to examine the effects of school environment modifications on student health are recommended.FundingThe National Institute for Health Research Public Health Research programme.

Background Existing guidance for developing public health interventions does not provide information for researchers about how to work with intervention providers to co-produce and prototype the content and delivery of new interventions prior to evaluation. The ASSIST + Frank study aimed to adapt an existing effective peer-led smoking prevention intervention (ASSIST), integrating new content from the UK drug education resource Talk to Frank (www.talktofrank.com) to co-produce two new school-based peer-led drug prevention interventions. A three-stage framework was tested to adapt and develop intervention content and delivery methods in collaboration with key stakeholders to facilitate implementation. Methods The three stages of the framework were: 1) Evidence review and stakeholder consultation; 2) Co-production; 3) Prototyping. During stage 1, six focus groups, 12 consultations, five interviews, and nine observations of intervention delivery were conducted with key stakeholders (e.g. Public Health Wales [PHW] ASSIST delivery team, teachers, school students, health professionals). During stage 2, an intervention development group consisting of members of the research team and the PHW ASSIST delivery team was established to adapt existing, and co-produce new, intervention activities. In stage 3, intervention training and content were iteratively prototyped using process data on fidelity and acceptability to key stakeholders. Stages 2 and 3 took the form of an action-research process involving a series of face-to-face meetings, email exchanges, observations, and training sessions. Results Utilising the three-stage framework, we co-produced and tested intervention content and delivery methods for the two interventions over a period of 18 months involving external partners. New and adapted intervention activities, as well as refinements in content, the format of delivery, timing and sequencing of activities, and training manuals resulted from this process. The involvement of intervention delivery staff, participants and teachers shaped the content and format of the interventions, as well as supporting rapid prototyping in context at the final stage. Conclusions This three-stage framework extends current guidance on intervention development by providing step-by-step instructions for co-producing and prototyping an intervention’s content and delivery processes prior to piloting and formal evaluation. This framework enhances existing guidance and could be transferred to co-produce and prototype other public health interventions. Trial registration ISRCTN14415936, registered retrospectively on 05 November 2014. Electronic supplementary material The online version of this article (10.1186/s12889-017-4695-8) contains supplementary material, which is available to authorized users.

Purpose: Interventions to improve school ethos can reduce substance use but “upstream” causal pathways relating to implementation and school-level changes are uncertain. We use qualitative and quantitative data from a pilot trial to build hypotheses regarding these. Methods: The Healthy School Ethos intervention involved two schools being provided with facilitation, training, and funding to plan and implement actions (some mandatory and some locally determined) to improve school ethos over one year. The evaluation involved a pilot-trial with two intervention and two comparison schools; semi-structured interviews with facilitators, staff, and students; and baseline and follow-up surveys with students aged 11 to 12 years. Results: Student accounts linked participation in planning or delivering intervention activities with improved self-regard and relationships with staff and other students. Some activities such as re-writing school rules involved broad participation. Students in receipt of actions such as peer-mediation or motivational sessions reported benefits such as improved safety and relationships. Some student accounts linked improved self-regard and relationships with increased engagement and aspirations, and reduced substance use. At 9-month follow-up, students in intervention schools reported less hurting and teasing of others and feeling unsafe at school. Other outcomes suggested intervention benefits but were not significant. Conclusions: School-ethos interventions may reduce substance use through upstream pathways involving the aforementioned factors. Future phase-III trials should quantitatively model the extent to which these mediate intervention effects.

Background: Despite concerns regarding youth drug use and ‘standards’ of drugs education in British schools, little is known about young people's routine experiences of drugs education at school, or schools’ other priorities, policies and practices relating to drugs. Methods: Qualitative data were collected through semi-structured interviews with students aged 14–15 (N = 50) and teachers (N = 10) at four schools in England. We used thematic content analysis to explore: young people's accounts of drugs education at secondary school and what they have learnt from this; and students’ and teachers’ accounts of schools’ wider policies and practices relating to drugs. Results: A recurring theme was that students reported having received little or no drugs education; the majority could not remember having had any at their secondary school. These students were not the ‘drugwise’ youth described in the normalisation thesis and young people wanted their school to provide them with more information. Teachers recognised that schools’ drugs policies were rarely implemented in practice and that drugs education was not a priority. Schools also appear to be adopting new strategies based on surveillance and targeting to control students’ drug use. In some cases referrals to a drugs counsellor were coercive and appeared to merely replace classroom-based drugs education. Conclusion: This study provides further evidence of the gap between drug policies and practice. It may be possible to increase the priority given to comprehensive drugs education and supportive drugs policies by modifying the incentive structures that schools work within. New targeted responses are unlikely to be effective at reducing drug-related harm at a population level because of the small number of students reached, and can be stigmatising. Further research is needed to explore schools’ focus on surveillance and targeted control rather than universal education, and to examine interventions that might ensure schools implement adequate drugs education.

PurposeEvidence from the USA/Australia suggests whole‐school interventions designed to increase social inclusion/engagement can reduce substance use. Completeness of implementation varies but contextual determinants have not been fully explored. Informed by previous interventions, the paper aims to examine these topics in an English pilot of the Healthy School Ethos intervention.Design/methodology/approachThis intervention, like previous interventions, balanced standardization of inputs/process (external facilitator, manual, needs‐survey and staff‐training delivered over one year to enable schools to convene action‐teams) with local flexibility regarding actions to improve social inclusion. Evaluation was via a pilot trial comprising: baseline/follow‐up surveys with year‐7 students in two intervention/comparison schools; semi‐structured interviews with staff, students and facilitators; and observations.FindingsThe intervention was delivered as intended with components implemented as in the USA/Australian studies. The external facilitator enabled schools to convene an action‐team involving staff/students. Inputs were feasible and acceptable and enabled similar actions in both schools. Locally determined actions (e.g. peer‐mediators) were generally more feasible/acceptable than pre‐set actions (e.g. modified pastoral care). Implementation was facilitated where it built on aspects of schools' baseline ethos (e.g. a focus on engaging all students, formalized student participation in decisions) and where senior staff led actions. Student awareness of the intervention was high.Originality/valueKey factors affecting feasibility were: flexibility to allow local innovation, but structure to ensure consistency; intervention aims resonating with at least some aspects of school baseline ethos; and involvement of staff with the capacity to deliver. The intervention should be refined and its health/educational outcomes evaluated.

We draw on case‐study research at a high‐achieving secondary school in London to illustrate how school experiences may influence drug use and reproduce inequalities in reconstructed ways in late modernity. Qualitative data were collected through semi‐structured interviews with students and teachers, and observations. We focus in particular on the accounts of three female students expressing a shared counter‐school identity and style to explore how drug use has become an important source of bonding, identity construction, coping and excitement for young women from disadvantaged families at high‐achieving schools, including as part of strategies to resist the narrow focus schools can place on academic attainment, monitoring and discipline. We propose that, in late modern times, class‐based counter‐school cultures are being replaced with new consumer‐based ones, but that secondary schools continue to act as sites for the reproduction of social stratification, as well as risk and harm relating to drug use.

Purpose: To explore young people's experiences of school and drug use, generate hypotheses regarding the pathways through which schools may influence students’ drug use, and examine how these may vary according to students’ sociodemographic characteristics. Methods: Qualitative data were collected through semistructured interviews with 30 students (aged 14–15) and 10 teachers in two case-study schools. Students were purposively sampled to encompass variations in socioeconomic status, gender, ethnicity, and school engagement. Techniques associated with thematic content analysis and grounded theory were used to analyze the data and generate hypotheses. Results: Three potential pathways via which school effects on drug use may occur were identified: (1) peer-group sorting and drug use as a source of identity and bonding among students who are disconnected from the main institutional markers of status; (2) students’ desire to “fit in” at schools perceived to be unsafe and drug use facilitating this; and/or (3) drug use as a strategy to manage anxieties about school work and escape unhappiness at schools lacking effective social support systems. Conclusions: Various pathways may plausibly underlie school effects on drug use. These support the idea of “whole-school” interventions to reduce drug use through: recognizing students’ varied achievements and promoting a sense of belonging, reducing bullying and aggression, and providing additional social support for students. Such interventions should be piloted and evaluated in a range of settings to examine effects on students’ drug use. Broader policies relating to secondary school targets, curricula, assessment, and streaming may also influence rates of adolescent drug use.

Purpose – The limited evidence of effectiveness of existing teenage pregnancy strategies which focus on sex education, together with growing evidence that factors such as poor school ethos, disaffection, truancy, poor employment prospects and low expectations are associated with teenage pregnancy, has increased interest in interventions which target these “wider” social determinants. This paper aims to identify promising interventions and priorities for future research and to make recommendations for policy and practice in the UK. Design/methodology/approach – This paper discusses the evidence regarding the potential of interventions which target determinants of teenage pregnancy relating to school disaffection and low expectations, drawing on recent systematic reviews and trials to consider future directions for research, policy and practice. Findings – High-quality research evidence illustrates the potential of two approaches to address determinants of teenage pregnancy relating to disaffection and low expectations. These are school-ethos interventions, which aim to facilitate a positive and inclusive school-ethos, strengthen school relationships and reduce disaffection; and targeted, intensive youth work interventions, which aim to promote positive expectations, vocational readiness and self-esteem through vocational and life-skills education, volunteering and work experience. Practical implications – Two forms of intervention which address key social determinants of teenage pregnancy – school-ethos interventions and targeted youth work interventions – require more attention from researchers and policy-makers. Originality/value – This paper calls for a shift in the research and policy agenda. In addition to interventions that aim to address proximal, individual factors, such as sexual health-related knowledge, there should be a more complementary focus on socio-environmental as well as targeted individual-focused interventions aiming to address the wider social determinants of teenage pregnancy.

BackgroundYouth bullying and other aggressive behaviours are a major public health concern owing to their impact on adolescent physical and mental health and well-being. Whole-school restorative approaches have been identified as a promising method of addressing aggressive behaviour but there have been no randomised trials undertaken to examine their effects.AimTo examine the feasibility and acceptability of implementing and trialling the INCLUSIVE (initiating change locally in bullying and aggression through the school environment) intervention in English secondary schools.DesignCluster randomised controlled pilot trial in eight schools (1 : 1 computer-generated random allocation post baseline by a statistician blind to the identity of clusters) and process evaluation.SettingSecondary schools in England (purposively sampled to ensure diversity).ParticipantsYear 8 students (aged 12–13 years), teachers, other school staff and intervention providers.InterventionWhole-school restorative approach to address bullying and aggression, involving the following standard processes: school action group formation and external facilitation to review needs assessment data, identify priorities, and plan and monitor school-level actions; staff training in restorative practices; and a new social and emotional skills curriculum.Comparison groupStandard practice.Main outcome measures(1) The primary outcome of interest was the feasibility and acceptability of delivering and trialling the intervention according to prespecified criteria; (2) process data were analysed to explore participants’ experiences of implementing and trialling the intervention and how these varied according to school context; and (3) indicative primary outcomes (aggressive behaviour measures), secondary outcomes, intermediate outcomes and economic evaluation methods were piloted.Data sourcesStudents (n = 1144 baseline;n = 1114 follow-up) and teachers (n = 387 baseline;n = 336 follow-up) were surveyed at the start and end of the 2011–12 academic year (baseline September 2011; follow-up June–July 2012). A total of 1017 students surveyed at baseline remained in the study at follow-up (89%). Other quantitative data were collected via intervention provider checklists (n = 4) and action group surveys (n = 44); qualitative data were collected via interviews (n = 34), focus groups (n = 20) and observations of action group meetings (n = 16).Results(1) All prespecified feasibility and acceptability criteria were met. (2) Qualitative data indicated that all intervention components and the trial design were feasible and acceptable to students and staff, including in more disadvantaged school contexts. Qualitative data also suggested that student participation may be a core component in improving relationships and engagement across the school. The later-than-planned project start (July) and the timing of the baseline surveys (September), which needed to be completed pre allocation, caused delays in launching the intervention, staff training and other intervention outputs. (3) Three pilot primary outcomes were examined (completion rate at follow-up range: 91.7–94.2%) and the Gatehouse Bullying Scale and the Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale were acceptable, discriminating and reliable measures of bullying and aggression in this context. Our pilot economic analyses support the use of the Child Health Utility 9D scale with this population and the feasibility of cost–utility analysis, although this should be supplemented with a cost–consequence analysis. There was no evidence of harm.ConclusionsIt is feasible and acceptable to implement and trial the INCLUSIVE intervention in English secondary schools, although a longer lead-in time is required to enable timely intervention outputs to occur. A Phase III cluster randomised controlled trial is required to examine the effectiveness and cost-effectiveness over a 3-year period of implementation for reducing aggressive behaviours, promoting mental health and well-being, and reducing health inequalities.Trial registrationCurrent Controlled Trials ISRCTN88527078.FundingThe National Institute for Health Research Health Technology Assessment programme (research), the Paul Hamlyn Foundation, the Big Lottery Fund and the Coutts Charitable Trust (intervention). The report will be published in full inHealth Technology Assessment; Vol. 19, No. 53. See the NIHR Journals Library website for further project information.

In isolation, school-based health education is rarely an effective means of preventing youth health-risk behavior. Changing school cultures and classroom climates provides a highly complementary approach to traditional, individually focused health education and other prevention programs in schools in order to promote adolescent health more effectively. These efforts are consistent with the World Health Organization’s definition of a “health promoting setting,” which creates a healthy physical and social environment; integrates health-promotion principles into daily activities; and develops capacity to reach out, beyond the setting, into the broader community to support health. Schools that promote an inclusive ethos, supportive classroom environments, and caring student–teacher relationships can reduce students’ health-risk behaviors and improve academic attainment. This is best achieved through flexible, locally driven interventions. Three examples, from England, Australia, and the USA, are profiled.

Background Illicit drug use increases the risk of poor physical and mental health. Few effective school-based drug prevention interventions are available. We adapted an effective school-based peer-led smoking prevention intervention (ASSIST) to deliver information from the UK national drug education website, FRANK Methods We conducted a four-arm pilot cluster-randomised control trial of 1567 students aged 12–13 years in 12 schools in Wales. Three schools each (mean number students per year 131) were randomly allocated to: ASSIST+FRANK, FRANK friends, ASSIST, or usual practice which may or may not include drug eduation. ASSIST+FRANK is a peer-led smoking prevention intervention in UK Year 8 (ASSIST) followed by a drug prevention adjunct in Year 9 (+FRANK). FRANK friends is a stand-alone peer-led drug prevention intervention in Year 9. ASSIST involves 2 days off-site training, plus four follow-up sessions. +FRANK involves 1 day off-site training plus 3 follow-ups. FRANK friends involves 2 days off-site training and four follow-ups. Influential students were trained to disseminate information on the risks of drug use and minimising harms. Primary outcome was the acceptability of the +FRANK and FRANK friends, which was assessed through interviews with students, staff, parents, and intervention staff (n=66), structured observations of delivery (195), exploratory effectiveness analysis (multilevel logistic models), and estimated costs. Secondary outcome was the lifetime use of any illicit drugs at 18 months. Intention-to-treat analyses were conducted unmasked to the intervention allocation. This trial was approved by Cardiff University School of Social Sciences Research Ethics Committee (SREC/ 1103; ISRCTN 14415936). Findings All 12 schools were recruited, randomised, and retained (ASSIST+FRANK 419 students, FRANK friends 440, ASSIST 347, usual practice 361). At the 18 month follow-up the student retention rate was 93% (1460/1567). +FRANK and FRANK friends were acceptable to students, teachers, and parents, and delivered as intended, but FRANK friends was preferred over +FRANK. Some staff felt pressured to meet all the learning objectives for +FRANK in 1 day training versus 2 days in FRANK friends. There could also have been a lack of novelty for +FRANK peer supporters since they had previously experienced the ASSIST intervention. The odds of lifetime drug use at 18 months was marginally lower in both the +FRANK arm and the FRANK friends arm than in the usual practice arm (38 [12·4%] of 307 vs 34 [13·4%] of 254 [odds ratio 0·96, 95% CI 0·58–1·59] and 30 [9·3%] vs 34 [13·4%] [0·70, 0·39–1·24], respectively). The estimated cost per school was £1942 for +FRANK and £3041 for FRANK friends. All progression criteria were met. Interpretation Although both interventions were acceptable to students, teachers, and parents, FRANK friends was preferred over +FRANK. There is, therefore, sufficient evidence to warrant a full-scale cluster-randomised controlled trial of FRANK friends. Funding National Institute for Health Research Public Health Research programme (for the research), Public Health Wales (for the intervention delivery).

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 (

BACKGROUND: Systematic reviews suggest that interventions that address school organisation are effective in reducing victimisation and bullying. We successfully piloted a school environment intervention modified from international studies to incorporate 'restorative justice' approaches. This trial aims to establish the effectiveness and cost-effectiveness of the INCLUSIVE intervention in reducing aggression and bullying in English secondary schools. METHODS: DESIGN: cluster randomised trial. PARTICIPANTS: 40 state-supported secondary schools. OUTCOMES assessed among the cohort of students in year 8 (n = approximately 6,000) in intervention year 1. INTERVENTION: INCLUSIVE is a school-led intervention which combines changes to the school environment with the promotion of social and emotional skills and restorative practices through: the formation of a school action group involving students and staff supported by an external facilitator to review local data on needs, determine priorities, and develop and implement an action plan for revising relevant school policies/rules and other actions to improve relationships at school and reduce aggression; staff training in restorative practices; and a new social and emotional skills curriculum. The intervention will be delivered by schools supported in the first two years by educational facilitators independent of the research team, with a third locally facilitated intervention year.Comparator: normal practice. OUTCOMES: primary: 2 primary outcomes at student level assessed at baseline and at 36 months:1. Aggressive behaviours in school: Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale (ESYTC)2. Bullying and victimisation: Gatehouse Bullying Scale (GBS)Secondary outcomes assessed at baseline, 24 and 36 months will include measures relating to the economic evaluation, psychosocial outcomes in students and staff and school-level truancy and exclusion rates. SAMPLE SIZE: 20 schools per arm will provide 90% power to identify an effect size of 0.25 SD with a 5% significance level.Randomisation: eligible consenting schools will be randomised stratified for single sex versus mixed sex schools, school-level deprivation and measures of school attainment. DISCUSSION: The trial will be run by independent research and intervention teams and supervised by a Trial Steering Committee and a Data Monitoring Committee (DMC). TRIAL REGISTRATION: Current Controlled Trials ISRCTN10751359 (Registered 11 March 2014).

Background Structure and parenting within family of origin have been found to be determinants of sexual risk and teenage pregnancy in the general youth population. Few studies have examined determinants of sexual risk among disadvantaged young people; those that do have not examined teenage pregnancy outcomes. Methods: Longitudinal data from a cohort of multiply disadvantaged at-risk young people aged 13–15 years living in deprived neighbourhoods in England (n = 1285) were analysed to examine how family structure, communication with parents and parental interest in education were associated with heterosexual debut, contraception use, expectation of teenage pregnancy and teenage pregnancy. Results: At follow-up, young women living with both biological parents were less likely than other young women to become pregnant (odds ratio (OR) = 0.21, 95% confidence interval (CI): 0.04–0.97). Young women who could talk to their mothers about private things were less likely to expect to become a teenage parent (OR = 0.61, 95% CI: 0.37–0.99). Those whose parents cared very much how they did at school were less likely to report contraception nonuse (OR = 0.44, 95% CI: 0.21–0.93). After adjustment, no associations between any family factors and sexual health outcomes were found for young men. Conclusions: We found limited evidence for family-related effects on sexual health risk or teenage pregnancy among disadvantaged young women in England and no evidence of risk factors within the home environment for young men’s outcomes. This suggests that targeted family-based interventions may not be appropriate for addressing these outcomes.

Background: Owing to the limited effectiveness of traditional health education curricula in schools, there is increasing interest in interventions aiming to promote young people's health by modifying the school environment. Existing systematic reviews cannot determine whether environmental intervention is effective because they examine interventions combining environmental modifications and traditional health education. This gap is significant because school-environment interventions are complex to implement and may be sidelined in underfunded and attainment-focused school systems without evidence to support such an approach. This systematic review examined the effectiveness of school-environment interventions without health-education components on student health and inequalities. Methods: This was a systematic review of experimental/quasi-experimental studies of school-environment interventions. Sixteen databases were searched, eliciting 62 329 references which were screened, with included studies quality assessed, data extracted and narratively synthesised. Results: Sixteen reports of 10 studies were included, all from the USA and the UK. Five evaluations of interventions aiming to develop a stronger sense of community and/or improve relationships between staff and students suggested potential benefits particularly regarding violence and aggression. Two trials of interventions enabling students to advocate for changes in school catering and physical activity reported benefits for physical activity but not diet. Three evaluations of improvements to school playgrounds offered weak evidence of effects on physical activity. Conclusions: School environment interventions show the potential to improve young people's health particularly regarding violence, aggression and physical activity. Further trials are required to provide a stronger and more generalisable evidence base.

Background Preventing young people from taking up smoking is crucial to maintain and accelerate recent declines in smoking rates. Most prevention efforts have focused on schools, with almost no research conducted in further education settings, despite 44% of regular smokers indicating that they started smoking between the ages of 16 and 19 years. Using data collected during the process evaluation of a smoking prevention feasibility trial in further education settings, we aimed to explore young people's beliefs and behaviour regarding smoking and smoking prevention in these contexts. Methods 11 focus groups of students (n=69) and six of staff (19) were conducted in three further education institutions (two colleges, one school sixth form) in Wales between May 1 and Sept 30, 2015. Focus groups included between two and 13 participants selected by convenience sampling. The groups covered views on student smoking behaviour, perceptions of the intervention, and perceived impact on student and staff smoking behaviours. Discussions were recorded, transcribed verbatim, and analysed in NVivo (version 10). All transcripts were coded line by line using a framework derived a priori from research questions and emergent indicative codes. Findings Students and staff expressed liberal, non-interventionist views about smoking. Though recognised as harmful, smoking was seen as a personal choice that should not be infringed, and students felt jaded by anti-smoking messages. Students used smoking behaviours to signify successful transition to adulthood—not by appearing grown-up, but by demonstrating their understanding of appropriate, responsible smoking behaviour (eg, protecting minors from second-hand smoke, being considerate to non-smokers). Staff commitment to fostering student autonomy conflicted with their perceived duty of care and institutional rules. For example, one institution banned smoking, causing tension between students and staff, who tried to respect student autonomy while enforcing the rules. Interpretation Our findings highlight students' liminal identities and tensions that can manifest as further education staff and institutions attempt to safely accommodate and nurture young people's transition to adulthood. Smoking is denormalised among this population and students can be desensitised to smoking prevention messages in this setting. Interventions in further education must be sensitive to the transitions young people experience. Funding The National Institute for Health Research (NIHR) Public Health Research Programme funded the feasibility trial (13/42/02). The work was undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence.

Background Bullying and cyberbullying are common phenomena in schools and can have a significant impact on the health and mental health of those involved in such behaviours, both as victims and as bullies. This study aims to investigate student-level and school-level characteristics of those who become involved in bullying and cyberbullying behaviours. Methods We used data from 6667 year-8 students from the baseline survey of a cluster randomised trial in 40 English schools. We ran multilevel models to examine associations of bullying outcomes with individual-level variables (sex, ethnicity, family composition and family socioeconomic status) and school-level variables (school-level deprivation; school type; size of student population; school sex composition (mixed or single sex school) and measures of school quality. Results 32% of boys and 38% of girls report significant bullying victimisation, and cyberbullying victimisation was reported by 2% of boys and 4.5% of girls, with fewer (1% of boys and 0.5% of girls) reporting being cyberbullies. At the individual level, low socioeconomic status was associated with higher risk of reporting being a cyberbullying victim or perpetrator. Having a single parent was associated with increased risk of reporting being a victim of bullying or cyberbullying but not of reporting being a cyberbullying perpetrator. Being female was a risk factor for reporting being a victim of bullying or cyberbullying and a protective factor against reporting being a perpetrator of cyberbullying. At the school level, school type and school quality measures were associated with bullying risk: compared with students in converter academies mainstream, students in voluntary-aided schools were less likely to report being bullied. Students in community and foundation schools were more likely to report being perpetrators of cyberbullying. A school quality rating of “good” was associated with greater reported bullying victimisation compared to ratings of “excellent”. Discussion These results suggest that bullying and cyberbullying prevalence varies across school type and school quality, supporting the hypothesis that organisational/management factors within the school may have an impact on students’ behaviour. These preliminary findings will pave the way for future research investigating in detail what are the school factors and processes that promote/prevent bullying and cyberbullying behaviours.

Objectives: To assess the evidence of differences in the risk of HIV, sexually transmitted infections (STI) and health-related behaviours between migrant and non-migrant female sex workers (FSWs).\ud \ud Methods: Systematic review of published peer-reviewed articles that reported data on HIV, STIs or health-related harms among migrant compared with non-migrant FSWs. Studies were mapped to describe their methods and focus, with a narrative synthesis undertaken to describe the differences in outcomes by migration status overall and stratified by country of origin. Unadjusted ORs are presented graphically to describe differences in HIV and acute STIs among FSWs by migration and income of destination country.\ud \ud Results: In general, migrant FSWs working in lower-income countries are more at risk of HIV than non-migrants, but migrants working in higher-income countries are at less risk. HIV prevalence was higher among migrant FSWs from Africa in high-income countries. Migrant FSWs in all countries are at an increased risk of acute STIs. Study designs, definitions of FSWs and recruitment methods are diverse. Behavioural data focussed on sexual risks.\ud \ud Discussion: The lack of consistent differences in risk between migrants and non-migrants highlights the importance of the local context in mediating risk among migrant FSWs. The higher prevalence of HIV among some FSWs originating from African countries is likely to be due to infection at home where HIV prevalence is high. There is a need for ongoing monitoring and research to understand the nature of risk among migrants, how it differs from that of local FSWs and changes over time to inform the delivery of services.

Health outcomes vary between schools and it is theorised that this may be partly attributable to variation in the school environment. Existing systematic reviews have not drawn authoritative conclusions because of methodological limitations in the review or studies available. We identified 42 multi-level studies, ten of which were judged of sufficient quality to narratively synthesize. There was consistent evidence that schools with higher attainment and attendance than would be expected from student intake had lower rates of substance use. Findings on the influence of smoking/alcohol policies were mixed. Three studies examined the health effects variously associated with school campus area and observability, year structure, school size and pupil-to-teacher ratio with mixed findings. The studies reviewed support the potential influence of the school environment on student health.

Purpose: In order to consider the potential contribution of universal versus targeted prevention interventions, the authors examined what is the distribution of established risk variables for teenage motherhood? from where in these distributions do births arise? and how does this distribution/determination of risk vary between studies?\ud \ud Methods: Secondary data analysis of three British longitudinal studies.\ud \ud Results: For all cohorts and variables, the ‘risk’ category was the least frequent. Continuous risk factors were normally distributed. A high rate of teenage motherhood within a risk category often translated into low ‘contribution’ to the overall rate (eg, expectation to leave school at the minimum age among the 1989/1990-born cohort) and vice versa. Most young women had a low probability of teenage motherhood. For any targeting strategy, combining risk factors and a low threshold of predicted probability would be necessary to achieve adequate sensitivity. Assessing between-cohort applicability of findings, the authors find that the numbers of teenage parents is poorly estimated and estimates of the variability and direction of risk may also be inadequate.\ud \ud Conclusions: With reference to a number of established risk factors, there is not a core of easily identifiable multiply disadvantaged girls who go on to constitute the majority of teenage mothers in these studies. While individual risk factors are unlikely to enable targeting, a composite may have some limited potential, albeit with a low threshold for ‘risk’ and with the caveat that evidence from one population may not inform good targeting in another. It is likely that universal approaches will have more impact.

Background: School systems are increasingly typified by diversity of provision, parental choice and publication of performance data. Schools shape their students' lifestyles and health, but the effects of ‘marketisation’ are under-researched. The authors use qualitative data to develop a logic model regarding such effects. Methods: Case studies in seven English secondary schools, interviews with 103 students and 39 staff. Results: ‘Parental choice’ was associated with dispersal of students' friendship groups on transition to secondary school, reduced social support and emotional harms. ‘Choice’ meant some schools were regarded as ‘dumping grounds’ for socially disadvantaged students, creating potentially violent environments where students engaged in risk behaviours such as substance use to facilitate protective bonds with peers. Schools focused strongly on academic attainment, reflecting external pressures from the school inspectorate and performance league tables. Some schools sought to improve their league table position by targeting resources on ‘key marginal’ students on the threshold of passing five exams, the key metric. Less-academic students commonly became disengaged, engaging in various health risk behaviours as alternative status markers. The exam-focused environment aroused anxiety among high and low attainers, some using substances as self-medication. Schools also de-prioritised health education and sport in this performance-driven context. Conclusion: Our logic model aims to guide further research on how marketisation might affect young people health behaviours.

Background Schools may have important effects on students' and staff's health. Rather than treating schools merely as sites for health education, 'school-environment' interventions treat schools as settings which influence health. Evidence concerning the effects of such interventions has not been recently synthesised. Methods/design Systematic review aiming to map and synthesise evidence on what theories and conceptual frameworks are most commonly used to inform school-environment interventions or explain school-level influences on health; what effects school-environment interventions have on health/health inequalities; how feasible and acceptable are school-environment interventions; what effects other school-level factors have on health; and through what processes school-level influences affect health. We will examine interventions aiming to promote health by modifying schools' physical, social or cultural environment via actions focused on school policies and practices relating to education, pastoral care and other aspects of schools beyond merely providing health education. Participants are staff and students age 4-18 years. We will review published research unrestricted by language, year or source. Searching will involve electronic databases including Embase, ERIC, PubMed, PsycInfo and Social Science Citation Index using natural-language phrases plus reference/citation checking. Stage 1 will map studies descriptively by focus and methods. Stage 2 will involve additional inclusion criteria, quality assessment and data extraction undertaken by two reviewers in parallel. Evidence will be synthesised narratively and statistically where appropriate (undertaking subgroup analyses and meta-regression and where no significant heterogeneity of effect sizes is found, pooling these to calculate a final effect size). Discussion We anticipate: finding a large number of studies missed by previous reviews; that non-intervention studies of school effects examine a greater breadth of determinants than are addressed by intervention studies; and that intervention effect estimates are greater than for school-based health curriculum interventions without school-environment components.

Objective: To examine whether students’ school engagement, relationships with teachers, educational aspirations and involvement in fights at school are associated with various measures of subsequent substance use. Methods: Data were drawn from the Belfast Youth Development Study (n = 2968). Multivariate logistic models examined associations between school-related factors (age 13/14) and substance use (age 15/16). Results: The two factors which were consistently and independently associated with regular substance use among both males and females were student–teacher relationships and fighting at school: positive teacher-relationships reduced the risk of daily smoking by 48%, weekly drunkenness by 25%, and weekly cannabis use by 52%; being in a fight increased the risk of daily smoking by 54%, weekly drunkenness by 31%, and weekly cannabis use by 43%. School disengagement increased the likelihood of smoking and cannabis use among females only. Conclusion: Further research should focus on public health interventions promoting positive relationships and safety at school.

Background: Despite evidence of school effects on drug use, little is known about the social and institutional processes through which these may occur. This study explores how school experiences may shape young people’s drug-related attitudes and actions and adds to existing evidence highlighting the importance of drug use in young people’s identity construction and group bonding. Methods: Case study qualitative data were collected through semi-structured interviews supplemented with observations. Fourteen students aged 14–15 were interviewed in autumn 2006 and again in summer 2007. Five teachers were interviewed. Results: Inner-city secondary schools may constitute risky and insecure environments, and thereby act as structural forces in shaping how students form peer groups and respond to feelings of insecurity. Cannabis use – and identities constructed in relation to this – appeared to play a key role in how students manage insecurity. Black and dual-heritage students formed large, ‘safe’ ethno-centric school social networks and smoking ‘weed’ appeared to be an important source of bonding and identity. For some students, a vicious circle may exist whereby the process of ‘fitting in’ exacerbates difficult and conflicting relationships with teachers and parents, entrenches disengagement from education and leads to further cannabis use. There also appeared to be a diffusion of this ‘safe’ identity construction beyond these disengaged students. Cannabis and other drug use may also be an important safety strategy and source of bonding for pro-education students who need to be seen ‘getting high’ as well as ‘aiming high’. While some students constructed ‘safe’ and ‘sweet’ identities others were constrained by their position and resources at school. Conclusion: Inner-city schools may both reflect and reproduce existing patterns of drug use. The concept of risk hierarchies may be important when designing and evaluating school-based drug-prevention strategies.

HIV prevention efforts in South Africa are at a critical stage. Considerable investment in HIV/AIDS awareness and education through the media and other programs has been made in recent years. Previous surveys have found high levels of awareness among young people about HIV the means of transmission and the required sexual behavioral modifications. However surveys have also found that many sexually active youth still do not think of themselves as personally at risk of HIV infection and misconceptions about the transmission prevention and treatment of HIV/AIDS still exist. Broadcast and other media have a crucial role to play in promoting sustained behavior change for HIV prevention. However more research is needed to understand the reach of current media messaging as well as the types of messages that resonate most with young people. The purpose of the current study is to help inform the approach of the national public broadcasters and other broadcasters in South Africa to HIV/AIDS messagingand programming in the future as well as other principal actors in the field of HIV prevention. In order to do this we conducted a nationwide survey of young South Africans including questions designed to: Gauge what media young people use and how often they use it; Assess the general attitudes of young people towards broadcast media programming in relation to HIV/AIDS; Measure exposure to and attitudes about various HIV/AIDS communications campaigns that have run on radio and television; Determine young South Africans general feelings about their lives and their future; Assess the general level of HIV/AIDS awareness and knowledge among young people; Measure sexual behavior patterns and perceptions of risk of HIV infection. (excerpt)

The design of any interactive computer system requires consideration of both humans and machines. Software usability is one aspect of human??computer interaction that can benefit from knowledge of the user and their tasks. One set of methods for determining whether an application enables users to achieve their predetermined goals effectively and efficiently is task analysis. In the present study, a task analysis was applied to the graphical user interface of fatigue modelling software used in industry. The task analysis procedure allowed areas of usability improvement to be identified and then addressed with alternate interface prototypes. The present method of task analysis illustrates a practical and efficient way for software designers to improve software usability, user effectiveness and satisfaction, by involving users in the design process. 2004

Background Secondary schools are increasingly subject to quasi-markets in the UK, Europe and North America, typified by: diversity of school types; parents choosing where to apply; and government publishing school performance data. There is a paucity of research examining these policies potential for harming young people9s health. Aim To develop a logic-model of mechanisms by which market-oriented education policies might influence students9 health. Methods Qualitative case-study research conducted in seven secondary-schools in London and south-east England between 2006 and 2010. Data collected via semi-structured interviews with students aged 11–16 (N=103), school leadership team members (N=12), classroom teachers (N=23) and non-teaching staff (N=4), and observations. Techniques associated with thematic content analysis and grounded theory were used to analyse the data. Results Parental ‘choice’ of secondary-school, and complex admission policies, were associated with the dispersal of students9 friendship groups when transitioning from primary to secondary school, with consequent loss of social support and emotional harms. Greater ‘choice’ was also implicated in some schools being regarded as ‘dumping-grounds’ for socially-disadvantaged students and potentially violent, intimidating environments in which students engaged in risk-behaviours such as drug use and violence to develop protective bonds with peers. All case-study schools were strongly focused on academic attainment due to the emphasis on this from the national school inspectorate and in performance ‘league-tables’. Some schools sought to improve their league-table position by targeting resources on ‘key-marginal’ students on the threshold of achieving five exam passes, the key performance metric. Less academic students could become disaffected, engaging in smoking, drinking and other risk-behaviours as alternative markers of status and bonding, and with fewer reasons to avoid early parenting. The exam-focused environment also aroused anxiety among both high- and low-attainers, some of whom used drugs and solvents as self-medication. Schools also give low priority to any non-academic activities such as health education and sport in this performance-driven context. Conclusion Secondary schools may now be key sites for the production of health-risk and emotional harms, and by which health inequalities are reproduced. We propose a logic-model to guide further research illustrating how, via the above pathways, market reforms might encourage increased violence, substance use, teenage pregnancy, physical inactivity, poorer mental health and health inequalities.

Background:\ud There is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health?\ud \ud Methods:\ud Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach.\ud \ud Results:\ud Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks.\ud \ud Conclusion:\ud Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.