Background
The school environment is an important setting for promoting and supporting healthy lifestyles among children and youth [
1‐
3]. Schools provide an opportunity to reach a wide range of children over a considerable amount of time. Therefore, enhancing the school environment to promote and support healthy lifestyles can improve children’s health and well-being [
4] as well as academic performance [
5].
Comprehensive School Health (CSH) is
“an internationally recognised approach to supporting improvements in students’ educational outcomes while addressing school health in a planned, integrated and holistic way” [
6]. This approach may be referred to in other jurisdictions as health promoting schools, coordinated school health and healthy school communities. All of these approaches have similar underlying concepts, which are based on the World Health Organization’s Ottawa Charter for Health Promotion (1986). CSH uses an inclusive approach to promote health and educational achievement by engaging parents, the community and other stakeholders, along with the use of policies and programs to provide supportive social and physical environments [
7]. As a population-based approach to health promotion, CSH has the potential to reduce the risk of negative health outcomes by shifting the distribution of risk factors in a favourable direction [
8].
APPLE Schools is a school-based health promotion project that uses the CSH approach to create healthy school communities [
9]. Though it began in 2008 in ten elementary schools located in socio-economically disadvantaged neighbourhoods, it currently reaches sixty-three school communities in Northern Alberta [
9]. The mission of APPLE Schools is to inspire and empower school communities to lead, choose, and be healthy by recommending and supporting measurable and sustainable changes. APPLE Schools aim to effect change in the school, home and community by promoting healthy eating, physical activity (PA) and good mental health. Each school is provided with dedicated staff time in the form of a school health facilitator trained in nutrition, PA, and community development, who works with students, parents, school staff and community members to develop school action plans specific to the needs of each school [
9]. School action plans include, but are not limited to, student-led activities that are designed to make healthy living fun and engaging, such as planting classroom gardens, after-school cooking classes and PA programs [
9]. Baseline evaluations in 2008 showed that students in schools selected to be part of APPLE Schools had higher dietary energy intake, lower fruit and vegetable intake, lower PA levels and a higher prevalence of obesity compared to other students in Alberta [
10]. Subsequent evaluations have established the effectiveness of APPLE Schools in improving diets, increasing PA and reducing the prevalence of childhood obesity [
10‐
12]. However, the long-term effects of APPLE Schools, as with other CSH programs, have not been documented.
Few studies have conducted follow-up assessments on behaviour maintenance or continued effects of school-based interventions in the long-term, beyond the intervention endpoint or outside the intervention environment [
13]. The issues associated with the transition from one school environment to another, including losses to follow-up and difficulty acquiring appropriate sample sizes, make long-term evaluations challenging [
13,
14]. However, such evaluations are needed to determine behaviour maintenance and continued effects of intervention programs in improving healthy lifestyle habits in school settings, and to justify investments in such programs. We therefore assessed whether the effects of APPLE Schools on health-related knowledge, attitudes, self-efficacy, diet, PA, and weight status are sustained in junior high and high school students who attended an APPLE School in elementary school. Considering the relatively disadvantaged position of APPLE School students at baseline, we hypothesised that junior high and high school students who attended APPLE Schools in elementary school would have knowledge, attitudes, self-efficacy, health behaviours and weight status similar to that of students who did not attend APPLE Schools.
Results
The characteristics of students are shown in Table
1. Our sample included 13 junior high/high schools with an average of 41 participants from each school. The comparison school graduates included more girls (59.1% vs. 48.3%;
p = 0.021) and had a higher mean age (14.0 years vs. 13.8 years;
p = 0.045) than the APPLE School graduates. Significant differences existed in household income and geographic location (
p < 0.001), with greater proportions of APPLE School graduates being from families earning more than $100,000 per year and residing in cities. APPLE School graduates also reported lower health-related attitudes (2.72 vs. 2.81;
p = 0.04) and a higher percentage of overweight (44.6% vs. 32.3%;
p = 0.005) in comparison with graduates from comparison schools. No statistically significant differences were found for knowledge, self-efficacy, diet, PA-step counts, and obesity.
Table 1
Characteristics of APPLE School students, APPLE School graduates, comparison schools students and comparison schools graduates
No. of schools | 10 | 163 | 13 | 13 | |
No. of students | 277 | 3300 | 202 | 338 | |
Gender, % |
Girls | 50.2 | 52.0 | 48.3 | 59.1 | 0.021 |
Boys | 49.8 | 48.0 | 51.7 | 40.9 | |
Age, mean ± SD (years) | 10.8 ± 0.4 | 10.9 ± 0.4 | 13.8 ± 1.4 | 14.0 ± 1.3 | 0.045 |
Knowledge (mean ± SD)** | 2.73 ± 0.69 | 2.81 ± 0.71 | 3.26 ± 0.54 | 3.34 ± 0.49 | 0.07 |
Attitude (mean ± SD)** | 3.42 ± 0.55 | 3.44 ± 0.57 | 2.72 ± 0.51 | 2.81 ± 0.41 | 0.04 |
Self-efficacy for healthy eating (mean ± SD)** | 3.12 ± 0.63 | 3.11 ± 0.61 | 2.77 ± 0.73 | 2.81 ± 0.65 | 0.51 |
Self-efficacy for physical activity (mean ± SD)** | 2.99 ± 0.63 | 3.09 ± 0.59 | 2.91 ± 0.76 | 2.83 ± 0.71 | 0.259 |
Dietary outcomes |
Mean dietary energy intake (kcal)/d ± SD | 2117 ± 1242 | 1998 ± 1157 | 2173 ± 1034 | 2155 ± 1059 | 0.848 |
PA, mean ± SD |
Typical week, steps/d | 9081 ± 2638 | 9798 ± 2960 | 6810 ± 2549 | 6667 ± 2586 | 0.615 |
School days, steps/d | 9943 ± 2834 | 10,540 ± 3242 | 7616 ± 2833 | 7413 ± 2960 | 0.528 |
Non-school days, steps/d | 6928 ± 3799 | 7944 ± 3851 | 5177 ± 3476 | 5067 ± 3188 | 0.787 |
School hours, steps/h | 777 ± 218 | 839 ± 245 | 653 ± 221 | 634 ± 231 | 0.445 |
Non-school hours, steps/h | 621 ± 300 | 638 ± 55 | 340 ± 222 | 323 ± 227 | 0.488 |
Weight status |
Overweight, % | 44.4 | 37.6 | 44.6 | 32.3 | 0.005 |
Obesity, % | 19.5 | 14.0 | 18.7 | 15.7 | 0.381 |
Parental education, % |
Secondary or less | 30.5 | 27.2 | 23.0 | 21.8 | 0.112 |
College | 41.1 | 42.1 | 32.8 | 24.9 | |
University or above | 28.5 | 30.7 | 44.3 | 53.2 | |
Household income, % |
< $50,000 | 34.5 | 21.6 | 13.7 | 24.8 | p < 0.001 |
$50,001 - $100,000 | 37.4 | 40.4 | 15.3 | 34.2 | |
> $100,000 | 28.1 | 38.0 | 71.0 | 41.1 | |
Geographic Location, % |
Metropolitan | 64.9 | 24.9 | 23.8 | 60.2 | p < 0.001 |
City | 0.0 | 30.8 | 76.2 | 39.8 | |
Rural-town | 35.1 | 44.3 | – | – | |
Table
2 shows a cross-sectional comparison of graduates of APPLE Schools and comparison schools. APPLE School graduates did not significantly differ from comparison school graduates with respect to health-related knowledge, attitude, self-efficacy, diet, PA and weight status.
Table 2
Cross-sectional comparison of APPLE School graduates and comparison school graduates on knowledge, attitudes, self-efficacy, diet, physical activity and weight status
Knowledgeb | −0.15 (− 0.39, 0.09) |
Attitudeb | − 0.16 (− 0.42, 0.09) |
Self-efficacy for healthy eatingb | − 0.15 (− 0.39, 0.08) |
Self-efficacy for physical activityb | 0.14 (− 0.10, 0.39) |
Dietary outcomes |
Dietary energy intake (kcal/d) | −75.88 (− 316.65, 164.89) |
Physical activity |
Typical week, steps/d | −149 (− 865, 567) |
School days, steps/d | −303 (− 1113, 508) |
Non-school days, steps/d | −76 (−1177, 1026) |
School hours, steps/h | −9 (−66, 48) |
Non-school hours, steps/h | −16 (−79, 48) |
Weight status | (odds ratio and 95% CI)a |
Overweight | 1.25 (0.76, 2.08) |
Obesity | 0.99 (0.53, 1.85) |
Comparisons between elementary school (2008/09) and junior high/high school (2015/16) of self-efficacy, PA and weight status are presented in Table
3. After adjusting for covariates, the analysis showed that between 2008/09 and 2015/16, no statistically significant differences existed in self-efficacy for PA and self-efficacy for healthy eating. PA declined between 2008/09 and 2015/16 for both APPLE School graduates and comparison school graduates. The difference in step count between 2008/09 and 2015/16 in APPLE School graduates was not statistically different from the observed difference in comparison school graduates. The comparison of weight status between elementary school (2008/09) and junior high/high school (2015/16), also showed no statistically significant differences between the two groups.
Table 3
Comparisons of self-efficacy, PA and weight status between elementary school (2008/09) and junior high/high school (2015/16)
Self-efficacy (coefficient and 95% CI)b |
Self-efficacy for healthy eating (β and 95% CI) | 0.14 (−0.22,0.49) | 0.30 (− 0.02, 0.62) | − 0.16 (− 0.47, 0.14) | 0.048 |
Self-efficacy for PA (β and 95% CI) | 0.18 (− 0.010, 0.47) | −0.001 (− 0.27, 0.27) | 0.19 (− 0.09, 0.45) | 0.007 |
PA (coefficient and 95% CI) |
Typical week, steps/d | − 776 (− 2171, 620) | − 1571 (− 2912, − 230) | 795 (− 317, 1908) | 0.085 |
School days, steps/d | − 608 (− 2160, 944) | − 1260 (− 2747, 227) | 652 (− 582, 1886) | 0.096 |
Non-school days, steps/d | − 1150 (− 2985, 686) | − 1882 (− 3638, − 125) | 732 (− 770, 2235) | 0.042 |
School hours, steps/h | 54 (−76, 184) | −32 (−154, 90) | 86 (−17, 186) | 0.182 |
Non-school hours, steps/h | −235 (− 369, −102) | − 244 (− 374, −114) | 8 (−101, 117) | 0.041 |
Weight status (odds ratio and 95% CI) |
Overweight | 0.82 (0.44, 1.54) | 0.85 (0.46, 1.56) | 0.96 (0.54, 1.72) | 0.017 |
Obesity | 1.35 (0.59, 3.12) | 2.36 (1.07, 5.20) | 0.57 (0.27, 1.20) | 0.039 |
Discussion
We assessed whether the effects of APPLE Schools are sustained in junior high and high school students who attended elementary schools participating in the project. APPLE School graduates did not significantly differ from comparison school graduates with respect to all outcomes (i.e. health-related knowledge, attitude, self-efficacy, diet, PA, and weight status. Comparisons of self-efficacy, PA and weight status in elementary school (2008/09) and junior high/high school (2015/16), also showed no statistically significant differences between the two groups.
APPLE School students started worse off with regards to healthy dietary habits, PA levels and obesity prevalence relative to other students [
10]. However, within two years of the APPLE Schools program, they showed substantial improvements such that energy intake, PA and weight status of students had become similar as that of students in comparison schools [
10]. We had hypothesised that the effects of the APPLE Schools program would remain and thus the absence of a difference between students from APPLE Schools and comparison schools would continue into junior high/high school. Therefore, finding no significant differences between the two groups suggests a possibility that the effects of APPLE Schools continue into junior high/high school. However, since both groups are now in the same junior high/high school environment, the lack of significant difference between the two groups could also be because the new school environment has an equalizing effect on the students regardless of where they started.
The decrease in PA-step counts between elementary school and junior high/high school in both APPLE School graduates and comparison school graduates reflects observations from other studies that PA generally declines in the transition from childhood through to adulthood [
13,
25‐
28]. This decline likely reflects the biological processes related to growth and maturation [
29,
30], and possibly the increasing social demands at the different life stages [
28]. Since lifestyle practices and habits are developed both in childhood and adolescence [
31,
32], the school environment can play an important role in promoting and supporting healthy lifestyles among children and youth [
1‐
3]. As the junior high/high school environment also exerts its own influence on student behaviours [
33‐
35], it is therefore insufficient to focus successful CSH programs only on elementary schools. Thus, there is a reasonable expectation that extending CSH programs into junior/high schools could mitigate the reduction in PA during adolescence, and consolidate healthy lifestyle messages and practices adopted in elementary school.
Some studies have assessed long-term effects of school-based health promotion, most of which are focused on PA outcomes. Lai, et al. [
13] systematically reviewed school-based interventions that focus on PA to assess whether they produced a sustained impact in children and adolescents. ‘Follow-up assessment’ was defined as data collection at least six months after post-intervention testing. Of the fourteen studies identified, ten studies measured and reported a sustained impact in PA. However, some reported a sustained impact only for boys or only for girls, and nine studies used self-reported methods of assessment. Tarro, et al. [
14] and Nader, et al. [
36] also reported sustained effects on PA, two and three years respectively after the cessation of the school-based intervention. These findings too were based on self-reported PA. Tarro, et al. [
14] also reported a reduced obesity prevalence. In contrast, Meyer, et al. [
37], objectively measured PA, three years after the cessation of an intervention in elementary schools. They found that apart from aerobic fitness, previously observed beneficial effects on PA (accelerometer measurements) and body fat after one year were not sustained in the intervention arm. The relatively short duration of the intervention (nine months) may have impacted the sustainability of the intervention. Systematic reviews of school-based PA programs among children and adolescents show that duration, frequency and intensity of interventions can influence the effectiveness of the interventions [
13,
38]. Thus, the most effective programs have characteristics such as being of long duration and high intensity, involving the whole school, being a multifactorial intervention, and comprising changes to the school environment [
39]. These are characteristics of APPLE Schools as well as some other CSH-oriented programs, which have demonstrated beneficial effects on students’ diet, PA and weight status [
35,
39,
40].
To our knowledge, this is the first study aimed at assessing the long-term effects of CSH (7 years after the initial implementation) on multiple outcomes – health-related knowledge, attitude, self-efficacy, diet, PA, and weight status. The strengths of this study include the uniqueness of the APPLE Schools project and the use of objective measures for PA and weight status. This study is not without limitations. First, we were unable to separate the effects of APPLE Schools from the effects of the new school environment because of the study design. High school students are likely to have spent a shorter time in APPLE Schools compared with junior high school students. However, our sample sizes were inadequate for the separate analyses, and such analyses may raise concerns about biases in attributing differences to an eroded effect of APPLE Schools. Furthermore, we did not account for duration (i.e. how long the elementary school had been an APPLE School) and intensity of the APPLE Schools intervention (i.e. number of days per week that the school had access to a school health facilitator). Varying durations and intensities in APPLE Schools could have impacted the outcomes of interest measured. The use of one 24-h recall instead of repeated 24-h recalls allowed the assessment of average intake at a group level but not the usual intake at an individual level. Another limitation is the cross-sectional design, by which causality cannot be established. Incomes in the more northern areas of Alberta, are inflated because of the economic boom and labour demands, which do not reflect on levels of education. Thus, parental education may be a better proxy for socioeconomic status in this sample rather than income. However, we adjusted for the socioeconomic status proxies (parent education, household income, geographic residence) in our analyses.