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Background: It is vital to improve the mental health (MH) of young people in Hong Kong, where the suicide rate has nearly doubled among those aged 15-29 years since 2014. This multi-method evaluation aimed to assess Coolminds, which promoted MH literacy by engaging students, parents, and educators in secondary schools in Hong Kong. Methods: Students, parents, and teachers completed self-report measures before and after attending workshops aimed at raising MH literacy. Pre- and post-survey data were collected between November 2021 and August 2022. Qualitative data from participant feedback and a focus group interview with Coolminds staff were analyzed using descriptive content analysis. Results: The final dataset included 2903 students, 395 parents, and 325 educators from 52 schools. Only 3 schools had engagement with all 3 key groups. Significant improvements in MH knowledge were observed after the Coolminds workshops for all 3 groups. Qualitative analysis identified a reactive approach to MH issues, and bureaucratic and logistical challenges as barriers to implementation. Conclusion: Findings support the effectiveness of the Coolminds curriculum in improving MH literacy for each group and the demand for MH promotions in school settings. The implementation challenges indicate the need for future initiatives to better align with local needs and practices.

Background: Nutrition plays a vital role in children's physical and emotional health. More than half of school age children's calories are provided in the school food environment, making school interventions an opportunity to address child nutrition. Methods: The Creating Health Environments for Schools (CHEFS) program is designed to leverage local resources to create customized solutions that improve the nutritional content of school food and encourage children to choose healthier food. There are 8 components: (1) customizing nutrition plans, (2) modifying/replacing menu items, (3) helping procure healthier food, (4) providing equipment grants, (5) training cafeteria staff, (6) implementing environmental changes and nudges, (7) engaging students and parents, and (8) supporting sustainability. Supporting child nutrition directors is key to facilitating cooperation with schools. Implications for School Health Policy, Practice, and Equity: Menu modifications and procurement are interrelated and depend on successfully collaborating with corporate, independent, and local food services organizations. Limited school budgets require low or no-cost solutions and staff training. Student and parent engagement are critical to facilitate culturally-appropriate solutions that increase awareness of healthy food. Conclusions: Every school district has particular resources and constraints. CHEFs engaged stakeholders to design customized solutions and encourage healthier nutrition for school children.

Background: More than 20 million children in the United States lack access to primary health care. Practice Learning: Research shows that students with regular access to physical and mental health services have fewer absences, are more social, less likely to participate in risky behaviors, have improved focus and higher test scores. Implication For School Health Policy, Practice, And Equity: School-based health centers (SBHCs) can be an important, valuable and viable health care delivery option to meet the full-range of primary health care needs of students where they spend the majority of their wake hours, ie, in school. Children in rural and other underserved communities, as well as those underinsured, non-insured, economically challenged, underserved, and the most vulnerable among us are especially at risk. Conclusions: This paper discusses the history, value, and importance of SBHCs from myriad perspectives, including physical and emotional wellbeing, academic and social success, and the promotion of a positive transition to adulthood. In addition, the authors' experiences that resulted in building the first SBHC in the Mid-Hudson Valley Region of New York State are shared. These experiences form the foundation for creating an important roadmap for individuals and school leaders that are interested in bringing a SBHC to their school and district.

Background: Medicaid is a key policy lever for expanding access to mental health services and supports for children in schools, especially low-income and minority children. This study examines how Medicaid finances mental health promotion and prevention (tier 1), screening and selected interventions (tier 2), and treatment (tier 3) in schools, informing policy recommendations to expand school mental health. Methods: Seventeen key informant interviews were conducted virtually from March to October 2022 with research, practice, and policy leaders in school mental health and Medicaid. Interview transcripts were thematically coded to inform recommendations. Results: Interview themes included that Medicaid is a key funder of mental health services, primarily in tier 3, and that braiding and blending funds is necessary to support services across all tiers in schools. Interviewees underscored the need to expand tier 2 in schools, to expand and diversify the behavioral health workforce (including via non-licensed providers, aligning school-employed provider licensure and billing requirements and building school-community referral relationships), strengthen teaming structures (including state children's cabinets, student case management, and education/Medicaid agency coordination), and leverage technical assistance and training to speed up adoption of new policies (including via guidance and templates that facilitate billing for school health services). Conclusions: Policymakers, practitioners, and advocates can use these findings to identify policies and strategies to expand school mental health and reduce inequities.

Background: The whole school, whole community, whole child (WSCC) model suggests wellness councils, ongoing review of wellness policy, and a plan for evaluating set objectives are some of the key features needed to support school wellness infrastructure. This study explored the relationship between implementation of these infrastructure features and overall school wellness environment assessment scores among a sampling of Pennsylvania schools. Methods: The Healthy Champions program provides Pennsylvania schools an opportunity to self-assess their wellness environments across several school wellness topics. Staff enrolled their school in the program by completing a self-report electronic assessment. Enrollment data from the 2020/2021 program year were analyzed using the Kruskal-Wallis test and linear fixed model to identify the impact of varied implementation levels across 3 wellness infrastructure activities. Interactions between these variables and overall assessment score were also analyzed. Results: Of the 645 Pennsylvania schools enrolled and analyzed, we observed higher mean wellness environment assessment scores ([delta] 0.74 95% CI 0.40-1.07; p < 0.001) among schools that reported some frequency of all 3 wellness infrastructure activities, compared to schools that reported no frequency for the activities. Implications: Schools with existing policies and practices related to the 3 wellness infrastructure activities should consider the degree of implementation to best support overall wellness in their school setting. Additional research to explore implementation barriers and supports is needed. Conclusions: Analyses indicated that overall wellness environment assessment scores are impacted by implementation thresholds for wellness council meeting frequency, revision of wellness policy, and review of student health promotion objectives.

Background: Youth may be reluctant to seek health care from school health providers due to feeling embarrassed or stigmatized in the health office environment or worried about their confidentiality. The purpose of this project was to create a set of youth-centered health posters that promote youth engagement with nursing staff and to standardize health messaging across high schools in Hawaii school-based clinics. Methods: Two community advisory boards, 1 composed of 10 youth stakeholders (mean age 17 years) and the other of 7 adult stakeholders, informed poster development utilizing web-based discussion groups. The discussions were transcribed, and additional data was collected using field notes and anonymous digital messages. Adult advisory board members also provided feedback on suggested poster text through an online survey. Results: Youth and adult advisory board participants identified 4 key health concerns facing youth: confidentiality, sexual health, relationships, and mental health. Based on input from the 2 advisory boards, 4 posters were developed, each centered on 1 key health issue. Implications for School Health Policy, Practice, and Equity: School-based posters can convey important messages to help youth understand their health care rights and responsibilities, as well as identify important issues open for discussion with nurses. Conclusion: Posters are an underutilized tool for school health providers to create welcoming, inclusive health care environments and facilitate health-related conversations with youth. This paper describes participant feedback about the characteristics of a memorable poster and briefly outlines current knowledge and recommendations for school health providers regarding each of the 4 health issues.

BACKGROUND: Schools play a significant role in adolescent sexual health (SH) promotion. Although adolescents' SH has improved, growing challenges still exist in some areas. Previous studies have noted a lack of knowledge about SH promotion implementation in school environments. The purpose of this review is to describe the contents, methods, and outcomes of adolescent SH promotion in school environments. METHODS: Three databases (Cinahl, ERIC, Medline) were searched for peer-reviewed articles published in 2011 to 2022, to identify SH promotion in school environments for adolescents aged 12 to 19 years old. After critical appraisal, inductive content analysis was conducted. RESULTS: After screening, 25 studies from 8 countries were included. Sexually transmitted diseases and contraception were emphasized in the contents of the methods. Five SH promotion methods were identified: traditional, virtual, interactive, practical skills supporting, and creative. The outcomes were advancement in SH abilities, changes in sexual behavior, and the strengthening of sexual identity. CONCLUSIONS: The contents mostly considered negative consequences of sexual behavior, whereas positive aspects were less discussed. Traditional methods were emphasized, yet positive outcomes were identified regardless of the method. SH promotion should aim to better support adolescents' sexual identity reinforcement.

Background: Students with intellectual and developmental disabilities (IDD) and the staff who support them were largely in-person during the 2021-2022 school year, despite their continued vulnerability to infection with SARS-CoV-2. This qualitative study aimed to understand continued perceptions of weekly SARS-CoV-2 screening testing of students and staff amidst increased availability of vaccinations. Methods: Twenty-three focus groups were held with school staff and parents of children with IDD to examine the perceptions of COVID-19 during the 2021-2022 school year. Responses were analyzed using a directed thematic content analysis approach. Results: Four principal themes were identified: strengths and opportunities of school- and district-level mitigation policies; experience at school with the return to in-person learning; facilitators and barriers to participation in SARS-CoV-2 screening testing; and perceptions of SARS-CoV-2 testing in light of vaccine availability. Implications for School Health Policy, Practice, and Equity: Despite the increased availability of vaccines, school staff and families agreed that saliva-based SARS-CoV-2 screening testing helped increase comfort with in-person learning as long as the virus was present in the community. Conclusion: To keep children with IDD in school during the pandemic, families found SARS-CoV-2 screening testing important. Clearly communicating school policies and mitigation strategies facilitated peace of mind and confidence in the school district. [This article was written for the COMPASS-T Study Group.]

Background: This study examined student and caregiver preference for school communication and explored the feasibility and acceptability of a digital tool to assist with communication about school meal program between schools and families. Methods: The study used qualitative methodology through youth focus groups and caregiver semi-structured phone interviews. The study was conducted in 4 high schools in a large, urban city. The phenomenon of interest included the exploration of preferences regarding communication around school meal programs and feasibility and acceptability of a digital tool for communication and promoting the ordering of healthful foods in the school environment. Interviews were transcribed, coded, and analyzed through NVivo qualitative software using thematic analysis approach to examine themes. Results: Forty-seven students (ages 14-21, grades 9-12) participated in 7 focus groups and 24 caregivers participated in semi-structured phone interviews. Three themes emerged around (1) communication preferences, (2) accessibility, and (3) extrinsic motivational factors for engagement in healthy eating behaviors. Conclusion: Results indicated that communication methods could potentially influence motivation and engagement in youth school meal participation.

Background: Since 2002, the Chinese Ministry of Education has conducted reform in the physical education (PE) curriculums of schools in China, with a focus on shifting from sports skills to regular participation in physical activity (PA) and promoting health. The aim of the study, therefore, is to examine the effects of school PE on the exercise habits of children and adolescents in China over time. Methods: Data based on 5941 observations of 3708 individuals aged 6 to 17 were collected from the China Health and Nutrition Survey (CHNS) for the period 2004 to 2015. The data were analyzed using the fixed-effect Logit model and the random-effect Tobit model. Results: The likelihood of exercising outside of school is 20.2% higher for students who have school PE than those who do not. Our study found that increasing the duration of PE at school by 100%, increases the duration of out-of-school PA by 22.3%. The variety of the types of sports schools offer encourages students to participate in out-of-school physical activity. The likelihood of students exercising outside of school increases by 5.6% when 1 more exercise type is provided in school PE. In addition, soccer, basketball, badminton, and volleyball education increases students' participation in after-school exercises. Soccer and basketball education, in particular, improves the duration of after-school PA. Conclusions: To form exercise habits in children and adolescents, we encourage the promotion of a variety of physical activities in schools, especially team sports such as soccer and basketball.

Background: The National School Lunch and School Breakfast programs reduce food insecurity and improve dietary intake. During the COVID-19 pandemic, school meals were provided to all children at no cost, regardless of income. This policy is known as Healthy School Meals For All (HSMFA). The purpose of the study was to examine the feasibility of a HSMFA policy in Utah. Methods: A mixed-methods approach was used, including qualitative interviews for policymakers, surveys for school foodservice directors, and financial modeling of Utah Child Nutrition Programs data. Analysis included a phenomenological analytic approach for qualitative data, descriptive statistics for surveys, and development of a cost model with 6 scenarios. Results: Qualitative data revealed themes of (1) awareness; (2) responsibility; (3) perspectives on school meals; and (4) new opportunities. Most (81%) foodservice directors believed HSMFA should continue post-pandemic. HSMFA would cost $51,341,436 to $82,358,375 per year. Implications for School Health Policy, Practice, and Equity: HSMFA would result in the equitable treatment of all children regarding access to healthy school meals. Conclusions: Given the support of foodservice directors but the lack of political consensus, considering stepwise implementation and providing cost estimates may increase feasibility of a HSMFA policy in Utah.

Background: Adolescents are considered to be vulnerable to particulate matter (PM). This study aims to develop and verify the effectiveness of the "school-based education program for coping with particulate matter (SEPC_PM)." This program was designed by employing the health belief model. Methods: High school students between the ages of 15 and 18 in South Korea participated in the program. This study employed a nonequivalent control group pretest-posttest design. A total of 113 students participated in the study; of these, 56 students participated in the intervention group, and 57 in the control group. The intervention group received 8 intervention sessions the SEPC_PM over the course of 4 weeks. Results: After the completion of the program, the intervention group's knowledge about PM showed a statistically significant increase (t = 4.79, p < 0.001). The practice of engaging in health-managing behaviors to protect against PM also showed statistically significant improvement in the intervention group, with the greatest progress in practicing precaution when outdoors (t = 2.22, p = 0.029). No statistically significant changes were observed regarding other dependent variables. However, a subdomain of the variable of perceived self-efficacy for engaging in health-managing behaviors to protect against PM (degree of body cleansing after returning home) demonstrated a statistically significant increase in the intervention group (t = 1.99, p = 0.049). Conclusions: The SEPC_PM may be proposed for incorporation into regular high school curricula to improve students' health by encouraging them to take necessary actions against PM.

Background: The worldwide COVID-19 government restrictions imposed on young people to limit virus spread have precipitated a growing and long-term educational and health crisis. Contributions to the Theory: This novel study used Sen's Capabilities Approach as a theoretical framework to examine the current health and educational impacts of COVID-19 on youth, referencing emerging literature. The objective was to inform the design of an internationally relevant framework for school health promotion to support young people through and after the COVID-19 pandemic. Mapping of existing health resources, internal/external conversion factors and capabilities were used to identify classroom, school and system level strategies that will enable young people to flourish. Four central enablers were identified and used in the design of the International Framework for School Health Promotion (IFSHP). Implications for School Health Policy, Practice, and Equity: The IFSHP can be used by educational institutions, school leaders and teachers to innovate existing health promotion programs, policies and practices to support young people through and after the COVID-19 pandemic. Conclusions: School systems, schools and teachers are encouraged to utilize the IFSHP to review and innovate existing school health programs to ensure they meet the increased physical and mental health needs of young people.

Background: This systematic review aims to identify out-of-school time (OST) interventions (eg, programming, policies) that increased opportunities for physical activity (PA) and healthy eating and/or improved youth PA and dietary behaviors. Methods: We searched for articles within systematic reviews that met our criteria (2010-2018) and for individual articles (2010-2020). Reviewer pairs screened articles, double-extracted data, assessed risk of bias (RoB), and achieved consensus. We included 71 articles (55 studies, 60 intervention arms). Results: Health (n = 3) and nutrition education (n = 7) interventions showed promising results, but most used weak designs and had high RoB. PA-focused interventions (n = 23) were largely consistent in improving fitness and moderate to vigorous PA during programming. Programmatic interventions that improved both PA and nutrition outcomes engaged family or community members (n = 4/13). Most organizational policy interventions improved the nutrition environment and student PA during OST. Conclusions: Organization-level policy and programmatic interventions can improve environmental supports and youth behaviors during OST programming, complementing school-day efforts to address student PA and dietary intake. To maximize their potential impact, OST programs need to be accessible to families. Administrators can consider actions to reduce participation barriers.

Background: Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services. Methods: This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States. Results: Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals. Conclusions: Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

Background: The school environment, consisting of the physical environment and social-emotional climate (SEC), plays a crucial role in both student and employee health; however, there is a lack of recent literature synthesizing school environment interventions in K-12 settings. We describe updated evidence about school environment interventions to support K-12 student and employee health in the United States. Methods: A 2-phase search included a review of reviews (2010-2018), followed by a search for individual articles (2010-2020) that targeted school physical environment and/or SEC to address physical activity (PA) and/or nutrition. We also investigated how nutrition and PA interventions with an SEC component improves social-emotional and/or mental health outcomes. Because research on dietary and PA behaviors for school employees is limited; we included studies on other worksites (eg, hospitals and offices) to provide insight for school employees. Findings: We identified 40 articles describing 40 unique studies and 45 interventions and grouped them by intervention type. Physical environment interventions demonstrated significant and positive nutrition and PA behavioral outcomes for students; outcomes among employees were mixed. Interventions with SEC components reported improvements in some mental health outcomes. Implications: The school environment can affect dietary and PA behaviors as well as mental health for students and employees. Conclusions: Establishing healthy school environments can support student and employee PA, dietary behaviors, and mental health.

Background: There are many ways to increase physical activity (PA) during the school day as part of a Comprehensive School Physical Activity Plan. This article reviews policies and practices that can be used during the school day to increase PA for students. Methods: We searched systematic reviews for articles that met criteria (2010-2018, phase 1), followed by a search for individual articles addressing topics for which we did not identify a sufficiently relevant or recent review or to update an earlier review that concluded insufficient evidence (2010-2020, phase 2). We included 45 articles (45 studies, 54 interventions). Results: We grouped studies by intervention type: school-wide PA approaches to reach all students within the school setting (17), physical education (PE) interventions (13), and interventions related to recess (15). Few studies involved secondary schools or rural settings. Among 45 studies reporting PA behavior or fitness outcomes, 37 reported at least 1 improvement. Conclusions: PA policies, PE, and recess can help improve school health by increasing the PA levels of students.

Background: The workplace is an important setting for health protection, health promotion, and disease prevention programs. In the school setting, employee health and well-being programs can address many physical and emotional concerns of school staff. This systematic review summarizes evidence-based approaches from employee health and well-being interventions supporting nutrition and physical activity (PA) in a variety of workplace settings. Methods: The 2-phase systematic review included a search for articles within systematic reviews that met our criteria (addressing employee health and well-being programs; published 2010-2018; Phase 1) and the identification of individual articles from additional searches (addressing school-based employee interventions; published 2010-2020; Phase 2). We included 35 articles. Findings: Across all studies and types of interventions and workplace settings, findings were mixed; however, multicomponent interventions appeared to improve health behaviors and health outcomes among employees. Implications for School Health Policy, Practice, and Equity: Schools can apply this evidence from employee health and well-being programs in various workplace settings to implement coordinated and comprehensive employee health and well-being programs. Conclusions: Employee health and well-being programs may be effective at supporting nutrition and PA. Schools can use findings from employee health and well-being programs in workplaces other than schools to support school staff.

Background: School efforts to promote health among students are more successful when families and community members are involved. Methods: We conducted a scoping review to summarize and categorize family and community engagement strategies used in US school and out-of-school time (OST) interventions to address physical activity (PA) and nutrition in kindergarten through 12th grade students. Results: The National Network of Partnership Schools' Six Keys to Success framework was useful in organizing the types of family and community engagement strategies used in included interventions. Many interventions used multiple family and community engagement strategies, with the most common being communicating with families and community members; providing support or education to families; and collaborations among school/OST program and community to support students and their families. Conclusions: This review identified six common family and community engagement strategies used in school and OST interventions for PA and nutrition. Including family and community engagement strategies in school and OST interventions could play an important role in maximizing support, resources, and expertise to promote healthy behaviors among all students.

Background: School-based health education can provide students with learning experiences that improve knowledge, attitudes, and perceptions (KAP) and behaviors regarding physical activity and nutrition. Methods: We conducted a 2-phase systematic review. Phase 1 was a review of reviews (ie, systematic reviews or meta-analyses) that were published 2010-2018. Phase 2 was a search for individual articles published 2010-2020 addressing topics relevant to our review; we searched for articles that had not been part of a sufficiently relevant or recent review or that had been part of a review that concluded that too few articles were available to assert sufficient evidence. Results: Forty-three studies were assessed: 20 randomized controlled trials and 23 quasi-experimental designs. Collectively, interventions had a favorable impact on students' PA and nutrition KAP, but behavioral and secondary outcome results (eg, body mass index) were mixed. Conclusions: Using the evidence-based health education strategies identified in this review can help contribute to improvements in students' KAP and behaviors.

Background: The context in which school-based health-promoting interventions are implemented is key for the delivery and success of these interventions. However, little is known about whether school culture differs by school deprivation. Methods: Using data from PromeSS, a cross-sectional study of 161 elementary schools in Québec, Canada, we drew from the Health Promoting Schools theoretical framework to develop four measures of health-promoting school culture (i.e., school physical environment, school/teacher commitment to student health, parent/community engagement with the school, ease of principal leadership) using exploratory factor analysis. One-way ANOVA with post-hoc Tukey-Kramer analyses was used to examine associations between each measure and social and material deprivation in the school neighborhood. Results: Factor loadings supported the content of the school culture measures and Cronbach's alpha indicated good reliability (range: 0.68-0.77). As social deprivation in the school neighborhood increased, scores for both school/teacher commitment to student health and parent/community engagement with the school decreased. Implications for School Health Policy, Practice, and Equity: Implementation of health-promoting interventions in schools located in socially deprived neighborhoods may require adapted strategies to address challenges related to staff commitment and parental and community involvement. Conclusion: The measures developed herein can be used to investigate school culture and interventions for health equity.

Background: Mental health literacy is important for awareness of mental illnesses in adolescence, which is the initial period of mental disorders. Determining the levels of mental health literacy guides studies in activities promoting mental health. This study aimed to determine the mental health literacy levels of high school students and teachers and related factors. Methods: Our study is a cross-sectional study. A total of 1051 people (students and teachers) were included in the Fatih District of Istanbul were included in our study. The mental health literacy levels of the participants were evaluated with the Mental Health Literacy Questionnaire. This questionnaire includes scenarios about mental problems called "vignettes" and questions about them. Results: Students' recognition percentages of depression, schizophrenia, and social phobia vignettes were found to be 28.1%, 46.5%, and 5.9%, respectively. For the person who was described in the vignettes, the "family physician" was chosen as the least by students and teachers. A statistically significant relationship was found between students' mental health literacy levels and sex, grade, father education levels, and experiencing vignette similar issues (p < 0.005). Additionally, teachers who were not school administrators and experienced vignette similar issues levels were higher (p < 0.005). Conclusions: These results showed us that mental health literacy levels are low in high schools. School-based intervention studies on this issue are of critical importance. In addition, it is seen that individuals do not consider asking for help with mental health problems from primary care services. This shows the inadequacy of the integration of primary health care services and mental health services.

Background: Implementation of Health Promoting School (HPS) programs can be challenging due to the dynamic school context. Navigating between program fidelity and adaptation, as well as integrating the program, is essential for successful implementation, and consequently, for program effects. As part of an evaluation study in the Netherlands, this study aimed to develop a measurement instrument that differentiates schools according to fidelity, adaptation, and integration of HPS implementation. Methods: This study presents the development and psychometric evaluation of the 28-item HPS Implementation Questionnaire, covering 7 dimensions: adherence, dose, participant responsiveness, quality of delivery, program differentiation, adaptation, and integration. The questionnaire, to be filled out by school employees, was developed for primary, secondary, secondary vocational, and special needs education, in close collaboration with experts (n = 54) in school health promotion. Results: Semi-structured interviews aimed at dimension clarification resulted in a list of 58 items. Items were revised, combined, and/or removed based on quantitative and qualitative feedback by the evaluation study's Community of Practice, 2-round expert consultation, and pre-tests. Psychometric evaluation (n = 535 schools), consisting of calculating Cronbach's a and confirmatory factor analysis (CFA), confirmed internal consistency ([alpha] > 0.72) and the 7-dimension framework. Conclusion: The brief yet comprehensive HPS Implementation Questionnaire offers possibilities for research into HPS implementation in various educational sectors and contexts, as well as self-monitoring by individual schools. This study provides first evidence for internal consistency and validity of the questionnaire.

Background: Interpersonal relationships undoubtedly have a bidirectional connection with the health of individuals and communities. Relational models based on equity contribute to well-being, while asymmetrical relationships based on hierarchies and differences of power negatively impact mental, physical, and social health. Methods: A conceptual framework for understanding the determinants of interpersonal relational models was developed. Results: Structural determinants were identified as the combined action of systems of oppression, the socio-historical context that normalizes violence, and social stratification and segregation, consequences which included inequitable access to power, resources, and opportunities. Intermediate determinants include individual, psychosocial, behavioral, and community aspects. Structural and intermediate determinants impact health and health inequalities through multiple relational patterns that are simultaneously established and sustained by individuals and communities. The health impact of inequitable relational patterns includes: Reduced self-esteem; anxiety, stress, and depression; acceptance of violence; physical and sexual harm; suicide; and murder. Conclusions: This conceptual framework allows for the modification of relational models by influencing structural and intermediate determinants. Six areas of intervention have been identified: educative policies, school governance, physical and symbolic space, school curriculum, school-community relations, and socio-educative interventions to promote healthy and equitable relationships. Healthy and equitable relationships are associated with improved subjective well-being, health status and protection from violence. Socio-educational interventions that consider the elements of this conceptual framework may be effective in promoting healthy and equitable relational models.

Background: Strategies used by wellness teams (WTs) to foster local wellness policy (LWP) implementation have been documented, yet there remains a need to better understand how WTs respond to district-level LWP requirements, particularly when bundled with additional health-related policies. This study's goal was to explore how WTs implement Healthy Chicago Public School (CPS), a district-led initiative focused on both LWP and other health policy implementation in the CPS district, one of the most diverse in the nation. Methods: Eleven discussion groups were conducted with WTs in CPS. Discussions were recorded, transcribed, and thematically coded. Results: Six overarching strategies used by WTs in working to achieve Healthy CPS include: (1) using district guides and resources to support planning, progress monitoring, and reporting; (2) under the leadership of wellness champions, as required by the district, facilitating engagement among staff, students, and/or families; (3) taking district guidance and adapting and integrating it into their schools' existing structures, curricula, and practices, often taking a holistic approach; (4) fostering linkages in the communities surrounding their schools to supplement internal school capacities; and (5) stewarding resources, time, and staff for sustainability. Implications: Strategies for LWP implementation by WTs in urban and diverse schools include planning for staff turnover, integrating health and wellness into existing curricula and structures, and leveraging relationships with the local community. Conclusion: WTs can play a critical role in supporting schools in diverse, urban districts to implement district-level LWP and the plethora of related policies that schools are subject to at the federal, state, and district levels.

BACKGROUND: Adolescents are more susceptible than originally thought to COVID-19, and they could play a significant role in community transmission. We aim to evaluate a health education program on students' declarative knowledge and risk awareness concerning COVID-19-related public health recommendations. METHODS: A quasi-experimental pre-post pilot study was conducted. A number of 487 students aged between 12 and 17 years old participated in an educational program. Following Socratic Method, preventive actions were simulated in order to encourage students to seek answers about the correct application of measures. The program covered 3 prevention areas: (1) practice hygienic handwashing; (2) instruction on the appropriate use of masks; and (3) promotion of physical distancing, and was implemented in class by 3 registered nurses. RESULTS: Following the educational program, declarative knowledge regarding handwashing and mask use improved along with the students' total score. In the pre-test, students 16 years and older as well as female students obtained higher scores in declarative knowledge. Age-dependent differences between groups vanished in the post-test, but girls still achieved better scores. CONCLUSION: This nurse-led health education program proved to be effective to enhance declarative knowledge about COVID-19-related public health recommendations.

Background: Schools are important arenas for the promotion of critical health literacy (CHL) among adolescents. Key domains of CHL are information appraisal, understanding social determinants of health, and abilities to act on determinants of health. In this paper, we examine the psychometric properties of the Critical Health Literacy for Adolescents Questionnaire (CHLA-Q). Methods: A cross-sectional survey study was performed at 5 schools in Norway. Respondents included 522 pupils aged 13-15 years old. Confirmatory factor analysis (CFA) was conducted to examine the structural validity. Internal reliability was assessed using ordinal Cronbach's alpha. Results: The estimated model had acceptable closeness of fit. Five of 6 scales displayed adequate internal reliability. Conclusion: The results indicate acceptable fit of the CHLA-Q framework and that 5 of the 6 scales are applicable to inform future research and interventions. More research is needed on measurement of the second domain of CHL.

Background: Since children are generally not achieving desirable levels of physical activity (PA), schools can provide an opportunity to increase their active time. This study aimed to describe individual- and social-level variables associated with PA at school recess in a culturally diverse primary school. Methods: This observational cross-sectional study included 131 children attending primary school. PA data were measured via accelerometry during school recess and analyzed in relation to data on sociodemographics, anthropometrics, and PA outside school. Data were analyzed using generalized linear modeling and logistic regression. Findings: Girls were more sedentary and engaged in less moderate to vigorous physical activity (MVPA) than boys (p < 0.001), while older girls were less active than younger girls (p < 0.001). Also, non-Caucasian children were less sedentary (p < 0.001) and engaged in more MVPA (p = 0.007). Belonging to ethnic minorities was also associated with lower socioeconomic status, higher body mass index, and less PA outside of school and on weekends. Conclusions: Girls (especially older girls) and children from lower socioeconomic contexts should be prioritized when promoting PA. Implications for School Health Policy: School recess can be used as an effective strategy aimed at increasing PA and reducing social inequalities.

Methods: Using the Theory of Planned Behavior (Ajzen 1991) as a theoretical framework, this study examined what administrators and teachers at a public elementary school located in a district in Northeast Georgia communicated as to their salient behavioral beliefs (attitude), normative beliefs (subjective norms), and control beliefs (perceived behavioral control) relative to the implementation of the district's written recess policy. Results: The results of this study demonstrated that teachers new to the field and those certified in early childhood education were more supportive of implementing the practice. The results further demonstrated that more experienced teachers and those certified in elementary education were less supportive. Implications for School Health Policy, Practice, and Equity: The findings in this study revealed that obtaining participant buy-in was critical for the implementation and that targeted professional development would be a suitable vehicle for improving school health for students. Conclusions: The most cited reasons for support for the policy were an understanding that an unstructured break was beneficial for students and that participants considered it a non-negotiable. The most cited reasons for a lack of support included more time needed for academics and a need for expanded behavioral consequences.

Background: The Healthy Hunger-Free Kids Act (HHFKA) of 2010 supported implementation of school gardens for promoting fruit and vegetable consumption. We examined school garden prevalence over time by school-level factors during the period before and after the implementation of HHFKA. Methods: Using data from the New Jersey Child Health Study, conducted in 4 low-income New Jersey cities, prevalence of school gardens among K-12 schools (n = 148) was assessed between school year 2010-2011 and 2017-2018. Multivariable analysis estimated changes in garden prevalence over time adjusting for school-level factors. Results: Overall, the sample included 97 elementary and 51 middle/high schools. Multivariable logistic regression showed that compared to 2010-2011 (19%) a higher proportion of schools reported having a garden in 2013-2014 (32%, p = 0.025). Over the entire study period, schools with majority Hispanic student enrollment had approximately half the odds of having a garden compared to schools with majority Black students (p = 0.036). Conclusion: School garden prevalence increased in the year immediately following the implementation of the HHFKA but this increase was not sustained over time. Future research should investigate the reasons for this decline and potential disparities by race/ethnicity.

Background: Engaging in classroom-based physical activity (PA) breaks may help increase children's subjective wellbeing and enjoyment of PA, important precursors for children to remain engaged in PA. We conducted a systematic review to investigate the effect of brief classroom-based PA interventions on primary school children's subjective wellbeing and enjoyment of PA. Methods: Databases were reviewed between the earliest date of records and April 2020. Eligibility criteria included peer-reviewed empirical quantitative or mixed methods studies reporting enjoyment of PA or wellbeing outcomes of participating in a brief classroom-based PA program. Fifteen papers were included. Interventions supported 7022 child participants enrolled at baseline and 6286 children analyzed in interventions across 148 schools. Results: Thirteen studies examined the effect of brief classroom-based PA interventions on subjective wellbeing. Four found a significant positive effect for children in the intervention group (specifically for children's self-efficacy in learning with video exercises, quality of life, and self-confidence). Eight studies examined the effect of brief classroom-based PA interventions on enjoyment of PA. Five studies reported a positive effect for children in the intervention group and only 1 study found a negative effect for 1 grade level of children in the intervention group. The remaining studies with wellbeing and/or enjoyment outcomes reported no significant effect. Conclusions: Findings from these studies indicate that the integration of brief PA breaks may support PA enjoyment and specific self-beliefs and quality of life perceptions that contribute to children's subjective wellbeing. However, more research is needed to confirm this effect.

Background: Exposure to injury and violence early in life increases the risk of experiencing injury and violence later in life. In 2019, the top 3 leading causes of death among 15- to 18-year-olds in the United States were unintentional injury, suicide, and homicide. This study examines the extent to which schools promote injury and violence prevention. Methods: This study examined injury- and violence-related school policies and practices using nationally representative data from the 2014 School Health Policies and Practices Study. The social ecological model served as the theoretical framework to identify level of impact. Results: For many injury-related topics, more than 75% of schools nationwide had relevant policies and practices to address those topics. However, this study showed differences in schools' injury-related policies and practices by urbanicity. Conclusions: Understanding and identifying gaps in school policies and practices is essential for reducing and preventing the injury and violence children experience. Collecting data on school policies and practices allows for better monitoring and evaluation to determine which are efficacious and aligned with the best available evidence.

Background: The COVID-19 pandemic caused an unprecedented move to emergency remote learning around the world, leading to increased digital screen time for children and adolescents. This review highlights the potential risk of increased screen time to the eye and general health and makes recommendations to mitigate the risks posed. Methods: A narrative review of evidence of increased digital time during the COVID-19 pandemic, the risks linked to increased screen time and offer possible steps to mitigate these in students. Results: Digital screen time was found to have increased for children and adolescents in all the studies examined during the pandemic and data suggests that this has an impact on eye and general health. We discuss the associated risk factors and adverse outcomes associated with increased digital screen time. Conclusions: This review offers evidence of increased digital time, highlights some of the well-known and not so well-known risks linked to increased screen time, and offers possible steps to mitigate these in children and adolescents during the pandemic, as well as offering schools and parents strategies to support the eye health of children and adolescents post-pandemic. We discuss a number of interventions to reduce the risk of eye strain, myopia, obesity, and related diseases that have been shown to be linked to increased digital screen time.

Background: The comprehensive school health (CSH) framework has four components: social and physical environment; partnerships and services; teaching and learning; and policy. This study examines associations between CSH and student physical activity (PA). Methods: Using 2015/2016 COMPASS study survey data of 37,397 students (grades 9-12) from 80 secondary schools in Ontario and Alberta, Canada, associations between school-level factors within CSH and student PA outcomes (weekly moderate-to-vigorous PA [MVPA] minutes and achieving the national PA recommendations of [greater than or equal to]60 min of MVPA daily, vigorous PA [greater than or equal to]3 days/week, strengthening activities [greater than or equal to]3 days/week) were analyzed using multilevel regression models stratified by gender and grade. Results: Factors within all four CSH components were associated with student PA. Four student subgroups were more likely to achieve the recommendations if their school had youth organization partnerships (Range of AORs:1.15-1.33, p <0.05) and female students were less likely if their school had low prioritization of PA (AOR = 0.77, 95% CI: [0.65-0.92]). Grade 9 students had higher MVPA when provided non-competitive PA opportunities ([beta] = 100.4, 95%CI: [30.0-170.9]). All student subgroups had better PA outcomes when schools provided access to equipment during non-instructional time. Conclusion: There is opportunity to improve student PA through CSH-guided interventions, but different strategies may be more effective for each gender/grade.

Background: Health promotion programs and interventions are designed to encourage behavioral changes in children, encouraging them to make safe and healthy life choices. This systematic review seeks to examine how social impact is measured in primary school health promotion interventions. Method: A systematic search and review process was used to identify and examine primary school health promotion interventions. The PRISMA guidelines were followed to source articles from 6 electronic databases reporting school health promotion programs or interventions in Australia, Canada, New Zealand, or the United Kingdom. Results: A total of 77 studies were located, representing 55 health promotion interventions delivered in primary school settings. Of these interventions, only 8 (15%) measured or attempted to measure social impact, whereas another 8 (15%) alluded to social impact. The predominant theories reported were social based theories (theories which examine the social influences on people, environments, and behaviors) (n = 17, 59%), with almost a third not informed by an overt health promotion framework or model (n = 34, 59%). A systematic rating system identified some level of stakeholder engagement (n = 30, 53%). Conclusions: This systematic review highlights the need for social impact measurement within health promotion to illuminate the role of school programs in delivering lasting change.

Background: Understanding teachers' appraisals of student wellness services and supports during COVID-19 is essential to strengthening services and improving student health outcomes. This mixed-method study aimed to examine US PK-12 teachers' appraisals of student wellness services and supports during COVID-19. Methods: This study focuses on qualitative data from 291 teachers' open-ended responses to the question: "What do you wish your school leaders knew about this (wellness support) aspect of your work?" and whose responses described wellness services and supports. A qualitative content analysis was conducted by an interdisciplinary research team using open- and axial coding. Results: Three main themes emerged. (1) insufficient access to mental health professionals and programming at schools, (2) concern about the quality of available services, and (3) a need for teacher professional development and support on student wellness. Statistically significant differences in teacher appraisals of insufficient access to mental health professionals and programming were found based on grade level taught and percentage of immigrant students in the school. Conclusion: With amplified student wellness needs, school personnel, including school leaders, must consider ways to allocate additional resources/staffing, assess the quality of services and supports, and design professional development opportunities to support teachers' involvement in supporting student wellness needs.

Background: School-based interventions and strategies targeting physical activity (PA) and eating patterns have successfully addressed unhealthy behaviors contributing to excess weight in school-age children. The purpose of this study was to investigate South Carolina (SC) public school administrators' perceptions of and experiences with weight-related issues in schools and associated barriers and facilitators to awareness, selection, and implementation of school-based healthy PA and eating interventions and strategies. Methods: This qualitative descriptive study, guided by the Social Ecological Model and the Steps in Quality Intervention Development Model, involved semistructured interviews with SC public school administrators from all academic levels (N = 28). Data were analyzed using thematic analysis. Results: Four themes were identified from interviews (N = 28): weight-related terminology or stigma, experiences with school-based healthy PA and eating interventions and strategies, barriers to school-based healthy PA and eating interventions and strategies, and facilitators to school-based healthy PA and eating interventions and strategies. Conclusions: Schools are well-positioned to provide interventions and strategies to improve PA and dietary habits leading to childhood obesity. School administrators, while knowledgeable and experienced with weight-related issues and school-based interventions and strategies, encounter barriers and facilitators that impact offerings and delivery. Understanding these challenges and supports is important in the development, adaptation, and implementation of school-based interventions and strategies focused on healthy PA and eating behaviors.

Background: Concerns have been raised over teachers' mental health literacy in low-income countries and lower- and middle-income countries wherein pediatric mental health resources are limited. This study aims to investigate adolescent depression literacy among teachers in Eswatini and to explore the role of urbanicity. Methods: We conducted a cross-sectional survey in 59 public high schools in Eswatini in 2019-2020. Data were collected by a paper-and-pencil questionnaire; depression literacy was assessed by the 17-item Adolescent Depression Knowledge Questionnaire. Results: Teachers' adolescent depression literacy item-level correct rates fell between 27 and 80%. Although the multivariate response models indicated that teaching in urban areas was slightly associated with having higher depression literacy in general (adjusted odds ratio [aOR] = 1.46; 95% confidence interval = 1.00-2.12), such urban-rural differences did not manifest homogeneously across all items: urban teaching was significantly linked with reduced correct responses toward certain items concerning depression etiology and treatment, including "depression runs in some families," "major stress as a necessary cause," and "a curable illness" (aOR = 0.57 [approximately] 0.68). Conclusion: Urban-rural differences in teachers' depression literacy were manifested at both scale- and item-levels. A critical need exists for urban/rural areas-tailored intervention on teachers' literacy toward mental disorders in the resource-limited regions to better improve health and developmental outcomes of students.

Background: This study evaluated the effect of the school-based intervention Charge Your Brainzzz on adolescents' social-cognitive determinants, sleep hygiene and sleep duration and quality. Methods: A cluster-randomized controlled trial was conducted with 972 students from 10 Dutch high schools. Schools were randomly allocated to the intervention (N = 5) or control condition (N = 5). Outcomes were measured with the digital Consensus Sleep Diary and via a digital questionnaire, based on valid measures. Data were collected at baseline (T0), ±1.5 weeks post-intervention (T1) and ±3 months post-intervention (T2). Mixed model analyses were performed to estimate the effects on social-cognitive determinants, sleep hygiene, and sleep outcomes. Results: The intervention increased sleep knowledge post-intervention (b = 1.91; 95%CI: 1.22-2.60) and at follow up (b = 1.40; 95%CI: 0.70-2.10). The intervention was also effective in changing adolescents' attitudes (b = 0.10; 95%CI: 0.01-0.19) and perceived behavioral control (b = 0.11; 95%CI: 0.01-0.22) post-intervention. No positive changes were found regarding subjective norms, behavioral intentions, sleep hygiene, or sleep outcomes. Conclusions: The intervention improved adolescents' sleep knowledge, attitude, and perceived behavioral control. To significantly impact sleep health, theoretically sound and systematically developed interventions are needed which take into account the interplay between sleep, sleep-related behaviors, and adolescents' social and physical environment.

Background: Given levels of sedentary behavior among youth, teachers have been called upon to increase physical activity (PA) by implementing classroom PA breaks. School-based interventions enacted in classroom settings have shown promise in increasing youth PA. Yet little is known about how teacher efficacy toward implementing classroom PA breaks may influence intervention effects. Purpose: Therefore, the purpose of this study was to examine how the Dearborn School Health through Integrated Nutrition and Exercise Strategies (D-SHINES) intervention, implemented across 8 schools, influenced classroom teacher's efficacy toward providing classroom PA breaks. Methods: A mixed-methods design examined classroom teachers' efficacy toward implementing classroom PA breaks and used semi-structured interviews to better understand teachers' efficacy and implementation. Results: Quantitative results indicated that teacher efficacy significantly increased over the intervention period and that general and institutional efficacy predicted higher amounts of PA breaks offered. Qualitative results suggested that to enhance teachers' facilitation of classroom PA breaks, one must tap into the institutional, student, and educational factors that constitute teacher efficacy. Implications for School Health: Designing interventions that focus on teacher efficacy toward classroom PA may be a viable way to increase PA breaks in schools. Implications for the whole school, whole community, whole child model are discussed.

Background: Concussions are a prevalent injury among youth, and concussion education has the potential to promote positive concussion-related behaviors. Recent recommendations and legislation have increased concussion education provided in schools; however, little is known about the education context, delivery method, development, and evaluation. A scoping review was conducted to identify peer-reviewed literature on concussion education delivered in the school setting. Methods: Six databases were searched (MEDLINE, CINAHL, EMBASE, PsycINFO, SPORTDiscus, and ERIC) to identify published articles from 2002 to July 16, 2020 that delivered concussion education in the school setting. Included studies described the concussion education and were written in English. Results: A total of 11,373 articles were identified and screened, with 27 studies meeting eligibility criteria and therefore, included. The studies delivered education to various stakeholders including students (n = 12; 44.4%), coaches (n = 5; 18.5%), educators (n = 3; 11.1%), parents (n = 1; 3.7%), and a mixed audience (n = 6; 22.2%). The education format varied and six studies (22.2%) developed the education based on a theory, model, or framework. Conclusions: This study found substantial variability in the context, delivery method, development, and evaluation of education delivered in schools and further evaluation of this education is needed to ensure it is best-suited for school-based stakeholders.

Background: Millions of school-aged children receive free or reduced-price lunches through the United States Department of Agriculture's (USDA) National School Lunch Program; that service was disrupted when public schools closed at the beginning of the coronavirus pandemic. Prior to the pandemic, this program received little attention on school districts' social media accounts. Methods: We collected Twitter data from 70 Ohio public school districts to construct a measure of attention paid toward school nutrition programs from 2008 to 2021. We also collected district-level data to analyze the relationship between district characteristics and mentions of school nutrition programs. Results: We show that attention to school nutrition programs significantly increased during the pandemic. School districts with a greater student population density and greater geographic area were more likely to tweet about these programs. Conclusions: School districts can, and should, use social media to inform residents about school nutrition programs and food security programs more generally. Social media provides a low-cost way to lessen the administrative burden for families trying to access these programs.

Background: Schools have a long history of delivering health services, but it is unclear how the COVID-19 pandemic may have disrupted this. This study examined changes in school-based health services and student needs before and during the pandemic and the factors important for delivering school-based health services. Methods: A web-based survey regarding the impact of the pandemic on school-based health services was distributed via email to all 1178 Virginia public elementary schools during May 2021. Results: Responding schools (N = 767, response rate = 65%) reported providing fewer school-based health services during the 2020-2021 school year than before the pandemic, with the largest declines reported for dental screenings (51% vs 15%) and dental services (40% vs 12%). Reports show that mental health was a top concern for students increased from 15% before the pandemic to 27% (P < 0.001). Support from families and school staff were identified by most respondents (86% and 83%, respectively) as very important for the delivery of school-based health services. Conclusions: Schools reported delivering fewer health services to students during the 2020-2021 school year and heightened concern about students' mental health. Understanding what schools need to deliver health services can assist state and local education and health officials and promote child health.

Background: School-based programs are widely implemented to address childhood obesity. Despite the promise of these programs, evidence on their effectiveness is mixed. Adopting a dissemination and implementation (D&I) science focus utilizing mixed methods can provide a broader understanding and more robust details about these programs. The goal of this evaluation is to understand how implementation factors and teacher experience influence implementation success and outcomes of the Integrated Nutrition Education Program (INEP), an elementary school-based nutrition program, using a mixed-methods design. Methods: Reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework guided the development of the evaluation and multiple methods were deployed. Hierarchical linear regression was used to assess the association between D&I construct variables within levels of influence and teacher perception of INEP impact from a quantitative end-of-year teacher survey. Follow-up qualitative interviews with teachers were analyzed using constant comparison analysis. Results: Workload and burden emerged as significant factors related to implementation in the quantitative analysis. The follow-up qualitative data collection identified other factors teachers found important to the adoption, implementation, and maintenance of INEP. Conclusion: Results of this evaluation can be used to inform program improvement efforts for INEP and provide information on ways to promote reach, effectiveness, adoption, implementation, and maintenance of similar school-based health promotion programs.

Background: Asthma is one of the leading causes of school absenteeism. Schools can play an important role in coordinating asthma care. The purpose of this study was to assess the implementation of asthma-related school health policies and practices across states and how they have changed over time. Methods: Data were analyzed from 36 states that conducted School Health Profiles surveys during 2008 to 2018. Trends in 6 topics were analyzed by logistic regression and JointPoint trend test. Results: Trends in efforts to identify and track students with asthma and improve students' and parents' knowledge about asthma were stable or increased. Interest among lead health education teachers in receiving professional development on asthma trended downward in 35 of 36 states. Conclusions: Stable to upward trends suggest that a majority of schools have maintained or improved their efforts to identify and track students with asthma and increase the knowledge of students and parents about asthma. However, further improvement is needed in referral of students with asthma to health care professionals and encouraging asthma-related professional development of lead health education teachers.

Background: Dental caries is the most common chronic illness for children. Caries can reduce the quality of life, cause missed classroom hours, and decrease cognition. Strategies to improve children's oral health must be evidence-based, developed, and implemented in consultation with communities. Methods: A community-academic partnership was formed between East Carolina University School of Dental Medicine and the Bertie County Public School District to develop and implement a school-based oral health prevention program using the PRECEDE-PROCEED Model. Results: The PRECEDE component involved social, epidemiological, environmental, educational, ecological, administrative, and policy factors that informed the development of the oral health program. The PROCEED component consisted of implementation and evaluation. Conclusions: School-based oral health programs can increase access to care for vulnerable children and improve learning. The application of the PRECEDE-PROCEED model proved to be a valuable method for developing, implementing, and evaluating a school-based oral health program.

Background: Active transportation to school (ATS) is a component of a whole school approach to health promotion among youth. Methods: Individual- and school-level predictors of ATS were examined using data from parent surveys (N = 11,100) of students in grades 3-8 attending 112 schools in Arizona (United States) administering Safe Routes to School (SRTS) programs between 2007 and 2018. Multilevel logistic models were estimated to predict the likelihood of students using active (walking or biking) versus inactive travel (riding bus or car) to and from school, and across distance and school-level income categories. Results: Student grade, parent education, asking permission to use ATS, perceived health and school support for ATS, distance, and school income were predictive of ATS. The impact of demographic factors persisted across distances of ½ mile or less and at low- and medium-income schools but diminished as distance and income increased. Asking permission and perceived school support persisted across levels of distance and income, while perceiving ATS as healthy was significant only for distances under 1 mile. Conclusions: SRTS programs should continue promoting health benefits and school support for ATS. SRTS may be particularly effective at low- and medium-income schools and among families living within ½ mile distances.

Background: We present results of the development and feasibility testing of CATCH Healthy Smiles, a school-based oral health program, among children in grades K-2 in Houston, Texas. Methods: Study design was cross-sectional (N = 2 schools; N = 125 parent-child dyads; 31 kindergarteners, 42 first graders, and 52 second graders). CATCH Healthy Smiles program was implemented by trained school teachers in the 2016-2017 school year. Trained dentists conducted dental assessments to measure dental caries increment score (d3mfs). Parent-reported 24-hour dietary recalls and surveys assessed child and parent behavioral, environmental, and psychosocial factors. Logistic regression analysis assessed factors associated with caries experience adjusting for covariates. Results: Of the 113 children with complete dental assessments, 54% children in grade K, 62% in first grade, and 73% in second grade had caries experience. Children with caries experience had a higher body weight (AdjOR = 1.13, 95% confidence interval [CI]: 1.02-1.29), were less likely to be girls (AdjOR = 0.22, 95% CI: 0.05-0.82), had greater odds of difficulty drinking hot or cold beverages because of dental problems (AdjOR = 13.13, 95% CI: 1.09-275.14), greater frequency of consuming sugar-sweetened beverages (AdjOR = 11.53, 95% CI: 2.10-87.19), greater odds of receiving government assistance (AdjOR = 14.62, 95% CI: 2.74-119.81), and lower odds of seeing a dental provider (AdjOR = 0.11, 95% CI: 0.02-0.45). Process evaluation showed that 100% of the CATCH Healthy Smiles lessons and activities were taught in the two schools with a high degree of program fidelity and acceptability across the schools, children, and parents. Conclusions: These data will be used to conduct a subsequent fully powered cluster randomized controlled trial.

Background: This study describes a method for harmonizing data collected with different tools to compute a rating of compliance with national recommendations for school physical activity (PA) and nutrition environments. Methods: We reviewed questionnaire items from 84 elementary schools that participated in the Childhood Obesity Research Demonstration (CORD) project, which was 3 distinct childhood obesity prevention projects in 7 communities in California, Massachusetts, and Texas. Each project used tools specific to its programs, schools, and communities. While this approach increased the feasibility of data collection, it created a challenge with the need to combine data across projects. We evaluated all questionnaire items and retained only those items that assessed one or more recommendations and constructed several items to indicate compliance or noncompliance with the respective associated recommendations. Results: Ten constructed items covered 11 of the 20 recommendations. Analysis indicated that the scores detected variability in compliance both among communities and among school within communities. Conclusions: The scores captured differences in compliance with the national recommendations at multiple levels. Our method, designed for creating common scores, may be useful in integrated data analysis, systematic reviews, or future studies requiring harmonizing of data collected via different tools.

Background: Conceptualizations of health have expanded to include indicators of adolescents' physical and mental wellness, rather than solely the absence of diseases or disorders. Although extensive research has identified links between mental and physical wellness, few studies have investigated the relationship between health promotion and happiness, particularly in adolescent populations who may be at particular risk for engaging in health-compromising behaviors, such as alcohol consumption. Methods: This cross-sectional study examined the relationship between 12 health-promoting behaviors and subjective well-being in a sample of 450 high school students from 2 states. Participants reported on their diet, physical activity, sleep hygiene habits, as well as abstinence from tobacco and alcohol products, and completed a multidimensional assessment of subjective well-being. Results: Findings demonstrated that 7 of the 12 health-promoting behaviors were significantly correlated with adolescents' subjective well-being. A sizeable portion of the variance in adolescents' subjective well-being (39.8%) was accounted for by the linear combination of the 12 health-promoting behaviors of interest. Increased physical activity, sleep hygiene cognitive/emotional factors, and bedtime routine all were identified as unique predictors of subjective well-being. Conclusions: These findings bring attention to the salience of daily physical activity and sleep hygiene and their associations with adolescents' happiness.