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Background This study examines the prevalence of dating and relationship violence (DRV) victimization, perpetration and joint victimization and perpetration, and associations between DRV and socio-demographic characteristics. Methods Cross-sectional self-report data from 74 908 students aged 11–16 from 193 schools across Wales were collected and analysed using generalized estimating equations to examine prevalence and predictors of emotional and physical DRV victimization, perpetration and joint victimization and perpetration. Results More girls reported emotional victimization (28%) and perpetration (18%) than boys (20% and 16%, respectively). More girls (8%) than boys (7%) reported physical perpetration. However, boys (17%) reported more physical victimization than girls (12%). Age-related trajectories of DRV victimization and perpetration were stronger in girls than in boys. Students from single or step parent homes, those in care, and certain ethnic minority groups had increased odds of DRV. No association was found between socioeconomic status and DRV. Conclusions Age-related trajectories and the lack of social patterning by socioeconomic status point to the value of early, universal interventions, while some evidence of ethnic patterning and family structure-related risk factors suggest areas for further research and targeted interventions. DRV continues to be a major public health problem for which little UK-specific intervention evidence exists. [ABSTRACT FROM AUTHOR]

Young people's wellbeing is often lowest where they assume a relatively low position within their school's socioeconomic hierarchy, for example, among poorer children attending more affluent schools. Transition to secondary school is a period during which young people typically enter an environment which is more socioeconomically diverse than their primary school. Young people joining a school with a higher socioeconomic status intake relative to their primary school may assume a relatively lowered position within their school's socioeconomic hierarchy, experiencing a detriment to their wellbeing as a consequence. This article draws on data from 45,055 pupils in Years 7 and 8, from 193 secondary schools in Wales, who completed the 2017 Student Health Research Network (SHRN) Student Health and Wellbeing (SHW) survey. Pupils reported which primary school they previously attended, and survey data on wellbeing were linked to publicly available data on the free school meal entitlement of schools attended. In cross‐classified linear mixed‐effects models, with primary and secondary school as levels, mental wellbeing varied significantly according to both primary and secondary school attended. A higher school‐level deprivation was associated with worse mental wellbeing in both cases. Mental wellbeing was significantly predicted by the relative affluence of a child's primary and secondary school, with movement to a secondary school of higher overall socioeconomic status associated with lowered wellbeing. These findings highlight transition to secondary school as a key point in which socioeconomic inequality in wellbeing may widen, and thus as an important focal point for intervention to reduce health inequalities. [ABSTRACT FROM AUTHOR]

BACKGROUND: Health and education are intrinsically linked, while both are significantly patterned by socioeconomic status throughout the life course. Nevertheless, the impact of promoting health via schools on education is seen by some as a "zero‐sum game"; ie, focusing resources on health improvement activity distracts schools from their core business of educating pupils, potentially compromising educational attainment. There is emerging evidence that school health improvement interventions may beneficially influence both health and attainment. However, few studies have examined the relationship between school health improvement activity and socioeconomic inequalities in educational attainment. METHODS: Wales‐wide, school‐level survey data on school health policies and practices was linked with routinely collected data on academic attainment. Primary outcomes included attendance and academic attainment at age 14 (Key Stage 3) and 16 (Key Stage 4). Linear regression models were constructed separately for high and low Free School Meal (FSM) schools, adjusting for confounders. Interaction terms were fitted to test whether there was an interaction between FSM, health improvement activity, and outcomes. RESULTS: There were positive associations between almost all school health variables and KS3 attainment among high, but not low FSM schools. Similarly, for attendance, there were positive associations of several health variables among high but not low FSM schools. There were no associations for KS4 attainment. CONCLUSIONS: Our findings did not support the "zero‐sum game" hypothesis; in fact, among more deprived schools there was a tendency for better attendance and attainment at age 14 in schools with more embedded health improvement action. [ABSTRACT FROM AUTHOR]

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. Onsite 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. [ABSTRACT FROM AUTHOR]

Health inequalities emerge during childhood and youth, before widening in adulthood. Theorising, testing and interrupting the mechanisms through which inequalities are perpetuated and sustained is vital. Schools are viewed as settings through which inequality in young people's health may be addressed, but few studies examine the social processes via which institutional structures reproduce or mitigate health inequalities. Informed by Markham and Aveyard's theory of human functioning and school organisation, including their concept of institutional boundaries, critical theories of marketisation and the concept of micro-political practices within schools, this paper presents analysis of student survey data ( N = 9055) from 82 secondary schools in Wales. It examines the role of socioeconomic composition, social relationships at school and institutional priorities in mitigating or perpetuating health inequality. It finds that affluent schools were most unequal in terms of student health behaviours and subjective wellbeing. In relation to health behaviours, students from affluent families accrue a disproportionate benefit. For wellbeing, students from poorer families reported lower subjective wellbeing where attending more affluent schools. Student-staff relationships appear to be a key mechanism underpinning these effects: poor relationships with staff were predicted by a pupil's position within schools' socioeconomic hierarchy and associated with worse health outcomes. That is, students from the poorest families reported better relationships with teachers where attending less affluent schools. Universal approaches engaging with these social processes are needed to reduce health inequalities. [ABSTRACT FROM AUTHOR]

Objective: Breakfast consumption has been consistently associated with health outcomes and cognitive functioning in schoolchildren. Evidence of direct links with educational outcomes remains equivocal. We aimed to examine the link between breakfast consumption in 9-11-year-old children and educational outcomes obtained 6-18 months later. Design: Data on individual-level free school meal entitlement and educational outcomes (Statutory Assessment Tests (SATs) at Key Stage 2) were obtained via the SAIL databank and linked to earlier data collected on breakfast consumption. Multilevel modelling assessed associations between breakfast consumption and SATs. Setting: Trial of the Primary School Free Breakfast Initiative in Wales. Subjects: Year 5 and 6 students, n 3093 (baseline) and n 3055 (follow-up). Results: Significant associations were found between all dietary behaviours and better performance in SATs, adjusted for gender and individual- and school-level free school meal entitlement (OR=1·95; CI 1·58, 2·40 for breakfast, OR=1·08; CI 1·04, 1·13 for healthy breakfast items). No association was observed between number of unhealthy breakfast items consumed and educational performance. Association of breakfast consumption with educational performance was stronger where the measure of breakfast consumption was more proximal to SATs tests (OR=2·02 measured 6 months prior to SATs, OR=1·61 measured 18 months prior). Conclusions: Significant positive associations between self-reported breakfast consumption and educational outcomes were observed. Future research should aim to explore the mechanisms by which breakfast consumption and educational outcomes are linked, and understand how to promote breakfast consumption among schoolchildren. Communicating findings of educational benefits to schools may help to enhance buy-in to efforts to improve health behaviours of pupils. [ABSTRACT FROM AUTHOR]

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

Background: Interventions to improve young people's health are most commonly delivered via schools. While young people attending the lowest socioeconomic status (SES) schools report poorer health profiles, no previous studies have examined whether there is an 'inverse care law' in school health improvement activity (i.e., whether schools in more affluent areas deliver more health improvement). Nor have other factors that may explain variations, such as leadership of health improvement activities, been examined at a population level. This paper examines variability in delivery of health improvement actions among secondary schools in Wales, and whether variability is linked to organisational commitment to health, socioeconomic status and school size.Methods: Of the 82 schools participating in the 2013/14 Health Behaviour in School-aged Children (HBSC) survey in Wales, 67 completed a questionnaire on school health improvement delivery structures and health improvement actions within their school. Correlational analyses explore associations of delivery of health improvement activity among schools in Wales with organisational commitment to health, socioeconomic context and school size.Results: There is substantial variability among schools in organisational commitment to health, with pupil emotional health identified as a priority by 52 % of schools, and physical health by 43 %. Approximately half (49 %) report written action plans for pupil health. Based on composite measures, the quantity of school health improvement activity was greater in less affluent schools and schools reporting greater commitment to health. There was a consistent though non-significant trend toward more health improvement activity in larger schools. In multivariate analysis deprivation (OR = 1.06; 95 % CI = 1.01 to 1.12) and organisational commitment to health were significant independent predictors of the quantity of health improvement (OR = 1.60; 95 % CI = 1.15 to 2.22).Conclusions: There is no evidence of an 'inverse care law' in school health, with some evidence of more comprehensive, multi-level health improvement activity in more deprived schools. This large-scale, quantitative analysis supports previous smaller scale, qualitative studies/process evaluations that suggest that senior management team commitment to delivering health improvement, and formulating and reviewing progress against written action plans, are important for facilitating the delivery of comprehensive interventions. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND Interventions to address inequalities in adolescent health behaviors often target children from less affluent families, or schools in poorer areas. Few studies have examined whether school- or family-level affluence predicts health behaviors independently, or in combination. METHODS This article reports secondary analysis of the Welsh Health Behavior in School-aged Children ( HBSC) survey. Mixed-effects logistic regression models test associations of school and family socioeconomic status ( SES) with smoking, fruit and vegetable consumption, alcohol consumption, and physical activity. RESULTS Higher family SES was associated with healthier behaviors, except in relation to alcohol consumption. For all behaviors except physical activity, school-level SES was independently associated with healthier behaviors. In higher SES schools, a stronger association of family SES with health behavior was observed, particularly in relation to smoking and physical activity. CONCLUSIONS School and family SES may exert independent and combined influences upon adolescent health behaviors. Targeting interventions toward deprived schools may fail to address substantial inequalities within more affluent schools. Targeting deprived families may fail to address behaviors of children from affluent families, attending more deprived schools. Identifying universal health improvement interventions which have greater effects among children from poorer backgrounds may be a more effective means of reducing inequalities. [ABSTRACT FROM AUTHOR]

ObjectivesUniversal interventions may widen or narrow inequalities if disproportionately effective among higher or lower socio-economic groups. The present paper examines impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning.DesignCluster-randomised controlled trial. Responses were linked to free school meal (FSM) entitlement via the Secure Anonymised Information Linkage databank. Impacts on inequalities were evaluated using weighted school-level regression models with interaction terms for intervention × whole-school percentage FSM entitlement and intervention × aggregated individual FSM entitlement. Individual-level regression models included interaction terms for intervention × individual FSM entitlement.SettingFifty-five intervention and fifty-six wait-list control primary schools.SubjectsApproximately 4500 children completed measures of dietary behaviours and cognitive tests at baseline and 12-month follow-up.ResultsSchool-level models indicated that children in intervention schools ate a greater number of healthy items for breakfast than children in control schools (b = 0·25; 95 % CI 0·07, 0·44), with larger increases observed in more deprived schools (interaction term b = 1·76; 95 % CI 0·36, 3·16). An interaction between intervention and household-level deprivation was not significant. Despite no main effects on breakfast skipping, a significant interaction was observed, indicating declines in breakfast skipping in more deprived schools (interaction term b = −0·07; 95 % CI −0·15, −0·00) and households (OR = 0·67; 95 % CI 0·46, 0·98). No significant influence on inequality was observed for the remaining outcomes.ConclusionsUniversal breakfast provision may reduce socio-economic inequalities in consumption of healthy breakfast items and breakfast skipping. There was no evidence of intervention-generated inequalities in any outcomes. [ABSTRACT FROM AUTHOR]

Purpose - Primary-care referral to community-based exercise specialists (exercise referral) is common in the UK despite limited evidence of effectiveness. A recent pragmatic randomised trial of the Welsh National Exercise Referral Scheme (NERS), demonstrated promising impacts upon physical activity and mental health. This paper presents a mixed-method process evaluation exploring how outcomes were achieved. Design/methodology/approach - Structured observation, implementer interviews and routine data assessed the extent to which NERS was implemented as intended. Baseline trial data were combined with routine monitoring data for the purposes of profiling uptake and adherence. Semistructured patient interviews explored processes of change and the emergence of social patterning in responses to the scheme. Findings - NERS offered patients a programme of supervised, group-based discounted exercise. However, motivational interviewing, goal-setting and patient follow-up protocols were delivered poorly. The high degree of professional support was perceived as helping patients to build confidence and assimilate into exercise environments. Patient-only classes provided social contacts, a supportive context and realistic models. Patterning in uptake emerged from access issues, with uptake lower among non-car owners. Adherence was poorer among mental health patients, younger patients and those who were least active prior to referral to NERS. Originality/value - In practice, although the NERS RCT demonstrated positive impacts on physical activity and mental health, process evaluation data indicate that the intervention was not entirely delivered as intended. Mixed-method process evaluation served crucial functions in understanding implementation and functioning, offering insights into the roles of professional support and exercise classes in promoting activity and mental health, and the emergence of social patterning in responses to an ERS. [ABSTRACT FROM AUTHOR]

Background Secondhand smoke (SHS) exposure is higher among lower socioeconomic status (SES) children. Legislation restricting smoking in public places has been associated with reduced childhood SHS exposure and increased smoke-free homes. This paper examines socioeconomic patterning in these changes. Methods Repeated cross-sectional survey of 10 867 schoolchildren in 304 primary schools in Scotland, Wales and Northern Ireland. Children provided saliva for cotinine assay, completing questionnaires before and 12 months after legislation. Results SHS exposure was highest, and private smoking restrictions least frequently reported, among lower SES children. Proportions of saliva samples containing <0.1 ng/ml (i.e. undetectable) cotinine increased from 31.0 to 41.0%. Although across the whole SES spectrum, there was no evidence of displacement of smoking into the home or increased SHS exposure, socioeconomic inequality in the likelihood of samples containing detectable levels of cotinine increased. Among children from the poorest families, 96.9% of post-legislation samples contained detectable cotinine, compared with 38.2% among the most affluent. Socioeconomic gradients at higher exposure levels remained unchanged. Among children from the poorest families, one in three samples contained >3 ng/ml cotinine. Smoking restrictions in homes and cars increased, although socioeconomic patterning remained. Conclusions Urgent action is needed to reduce inequalities in SHS exposure. Such action should include emphasis on reducing smoking in cars and homes. [ABSTRACT FROM AUTHOR]

Background: Though motivational interviewing (MI) has demonstrated efficacy in a range of behaviour change settings, effectiveness will require successful integration into everyday practice. This study examines implementers’ views on delivering MI within an exercise referral scheme and consistency of consultations with MI before and after a 2-day workshop. Method: Semi-structured interviews were conducted with 27 exercise professionals and 10 area coordinators delivering the Welsh National Exercise Referral Scheme (NERS), and the MI trainer. Eleven professionals provided consultation recordings before and 6-months after training, coded for fidelity using the Behaviour Change Counselling Index. Results: The workshop was well received by most, triggering increased recognition of potential motivational roles of consultations. However, some cited difficulties combining MI with structured data gathering activities, whilst a minority rejected MI, seeing current practice as effective, or MI as unnecessary because patients were ready to change. Although limited aggregate improvement in practice was observed, substantial improvements were observed in some individuals. Comments on the need for further practice or training were widespread. Conclusions: Efforts to implement MI should ensure that training and structures to provide monitoring and feedback are in place and that activities incorporated within consultations are compatible with MI delivery. [ABSTRACT FROM PUBLISHER]

Introduction: Secondhand smoke (SHS) exposure is higher among children from lower socioeconomic status (SES) households. Legislation banning smoking in public places has been linked with reduced SHS exposure in children. However, socioeconomic patterning in responses to legislation has been little explored. Methods: A total of 3,083 children aged 10–11 years, within 75 Welsh primary schools, completed questionnaires either before legislation or 1 year later. Saliva samples were provided by 2,787 of these children for cotinine assay. Regression analyses assessed socioeconomic differences in SHS exposure, and associations of legislation with exposure among children from low, medium, and high SES households. Changes in parental smoking in the home, car-based exposure, and perceived norms were assessed. Results: SHS exposure was highest among children from lower SES households. The likelihood of providing a sample containing an undetectable level of cotinine increased significantly after legislation among children from high [relative risk ratio (RRR) = 1.44, 95% CI = 1.04–2.00] and medium SES households (RRR = 1.66, 95% CI = 1.20–2.30), while exposure among children from lower SES households remained unchanged. Parental smoking in the home, car-based SHS exposure, and perceived smoking prevalence were highest among children from low SES households. Parental smoking in the home and children’s estimates of adult smoking prevalence declined only among children from higher SES households. Conclusions: Post-legislation reductions in SHS exposure were limited to children from higher SES households. Children from lower SES households continue to have high levels of exposure, particularly in homes and cars, and to perceive that smoking is the norm among adults. [ABSTRACT FROM AUTHOR]

Abstract: Aims: This study aims to explore associations of attitudes towards breakfast, self-efficacy and normative perceptions (in relation to parents, peers and teachers) with breakfast skipping in 9–11-year-old schoolchildren in Wales. Methods: A cross-sectional design was employed. Data were collected using self-report measures of attitudes towards breakfast, parental and peer descriptive norms, parental, peer and teacher related injunctive norms, self-efficacy for eating breakfast and self-reported habitual breakfast skipping. Participants were 1672 year 5 and 6 pupils within 52 schools in 9 local education authorities across North, South and West Wales. Results: Bivariate analyses indicated that all variables, with the exception of peer-related injunctive norms, were associated with breakfast skipping. In multivariate ordinal logistic regression analyses, adjusted for clustering at the school-level, only attitudes towards breakfast, parental descriptive norms and self-efficacy for eating breakfast were significantly associated with breakfast skipping. Conclusions: The associations reported in this paper highlight the need to consider attitudinal and normative factors when attempting to facilitate change in children''s breakfast eating behaviours, as well as investigating means of enhancing self-efficacy. Impacts of school breakfast provision on these factors, as well as the impact of these factors on uptake of school breakfast provision merit investigation. [Copyright &y& Elsevier]

Background: Smoke-free legislation was introduced in Wales in April 2007. In response to concerns regarding potential displacement of smoking into the home following legislation, this study assessed changes in secondhand smoke (SHS) exposure amongst non-smoking children. Methods: Approximately 1,750 year 6 (aged 10-11) children from 75 Welsh primary schools were included in cross-sectional surveys immediately pre-legislation and one year later. Participants completed self-report questionnaires and provided saliva samples for cotinine assay. Regression analyses assessed the impact of legislation on children's SHS exposure at the population level, and amongst subgroups defined by parental figures who smoke within the home. Results: Geometric mean salivary cotinine concentrations were 0.17 ng/ml (95% CI 0.15,0.20) prelegislation and 0.15 ng/ml (95% CI 0.13,0.17), post-legislation, although this change was not statistically significant. Significant movement was however observed from the middle (0.10-0.50 ng/ ml) to lower tertile, though not from the higher end (>0.51 ng/ml) to the middle. Reported exposure to SHS was greatest within the home. Home-based exposure did not change significantly post-legislation. Reported exposure in cafés or restaurants, buses and trains, and indoor leisure facilities fell significantly. The proportion of children reporting that parent figures smoked in the home declined (P = 0.03), with children with no parent figures who smoke in the home significantly more likely to provide saliva with cotinine concentrations of <0.10 ng/ml post-legislation. Amongst children with no parent figures who smoke in the home, the likelihood of "not knowing" or "never" being in a place where people were smoking increased post-legislation. Conclusion: Smoke-free legislation in Wales did not increase SHS exposure in homes of children aged 10-11. Reported SHS exposure in public places fell significantly. The home remained the main source of children's SHS exposure. The legislation was associated with an unexpected reduction in cotinine levels among children with lower SHS exposure pre-legislation. The findings indicate positive rather than harmful effects of legislation on children's SHS exposure, but highlight the need for further action to protect those children most exposed to SHS. [ABSTRACT FROM AUTHOR]

The authors comment on the suitability of randomised controlled trials (RCT) for evaluation of public health interventions and inequities according to authors C. P. Bonnell and S. Cousens et al. in the "Journal of Epidemiology and Community Health." They suggest breaking the barriers between researchers and between policymakers and practitioners to address evaluation problems. They also believe that targeting needy areas by policymakers does not hinder randomisation.

The author focuses on the relationship between breakfast eating habit and school performance. He mentions that the Primary School Free Breakfast Initiative in Wales reflects the increase in attention provided to the role of breakfast in improving school performance. He cites several approaches made to the study of the associations between breakfast consumption and cognition. He adds that a study by N.S. Gajre et al. published within the issue provides tentative evidence about the benefits of breakfast to the performance of children in school.

This paper draws upon data from two separate studies to consider sexual health outcomes for young people in state care in Wales. Cross sectional analysis of the School Health Research Network Survey (2015) examined sexual health behaviours and outcomes of young people in foster care compared to those living in private households. The findings are contextualised with qualitative data (collected 2016) from social care professionals about their practice experiences of supporting sexual health development and seeking to prevent early pregnancy for young people in state care. Findings suggest that young people in state care in Wales experience poorer sexual health outcomes compared to those not in care. Insights from professionals suggest that whilst the state care system has the potential to identify and respond to young people's needs, its effectiveness can be compromised by issues of resources, value-based judgements related to the age at which young people could and should be sexually active, and individual choice and determinism. It is suggested that statutory monitoring of sexual health related outcomes is required, together with a review of policy and practice ‘with’, rather than ‘for’, young people in state care. Finally it is argued that increased attention on the quality as well as the quantity of relationships young people in state care have with carers and professionals may provide a simple but powerful policy approach in continued efforts to secure parity in respect of sexual health and development. [ABSTRACT FROM AUTHOR]

(1) Background: This study examines the associations between risk behaviours and adolescent emotional and physical dating and relationship violence (DRV) victimisation and perpetration, and how these vary by gender. The risk behaviours explored include bullying, cyberbullying, sexting, alcohol, and cannabis use; (2) Methods: Cross-sectional self-report data from the School Health Research Network (SHRN) 2019 Student Health Wellbeing (SHW) survey of 48,397 students aged 11-16 from 149 schools across Wales were analysed using single and multiple-behaviour logistic regression models to explore the associations between each risk behaviour and emotional and physical DRV victimisation and perpetration; (3) Results: Bivariate analyses revealed a statistically significant association between DRV and all risk behaviours. In multivariate analyses, students who reported bullying, cyberbullying, sexting, and substance use, compared to those that had not, had significantly higher odds of experiencing and perpetrating emotional and physical DRV; and (4) Conclusions: Future studies on DRV should consider a mixed-methods approach to explore the context in which DRV and risk behaviours interrelate. Results from this study indicate the possibility that prevention and intervention programmes in school settings that seek to develop healthy school environments and peer-to-peer relationships, could inadvertently reduce the occurrence of future DRV and associated risk behaviours.

Background: Gambling opportunities are increasingly available and acceptable to many adolescents. Adolescent problem gambling has been associated with poor outcomes, such as lower reported physical and mental health. While much research has focussed on 'problem' gambling, analysing the distribution and determinants of experimentation with gambling is important in order to understand its normalization and population level consequences. This study describes the distribution of inequalities and socioemotional harms associated with adolescent gambling., Methods: Data were drawn from a subsample of students (N = 37 363) who completed gambling questions as part of the 2017 School Health Research Network Student Health and Wellbeing Survey, representing 193 secondary schools in Wales. Using imputations, we estimated a series of single-predictor and multi-predictor regressions for count of gambling behaviours, any gambling in the past 12 months and socioemotional harms of gambling., Results: Approximately two-fifths (41.0%) of respondents reported gambling in the past 12 months, of whom 16.2% reported feeling bad as a result of their own gambling. We found significant sex differences in gambling, with boys gambling more frequently than girls. Adolescents from more affluent families reported a higher count of gambling behaviours and socioemotional harms, although paradoxically, increasing affluence was also associated with lower prevalence of gambling in the last year. Non-White British ethnicities and students who felt less connected to school were more likely to engage in gambling and experience socioemotional harms., Conclusions: Our findings provide important new insights regarding risk factors in adolescence associated with gambling behaviours and socioemotional harms., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Public Health Association.)

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

Objective: Small increases in smoking restrictions in cars and homes were reported after legislation prohibiting smoking in public places. Few studies examine whether these changes continued in the longer term. This study examines changes in restrictions on smoking in cars and homes, and child exposure to secondhand smoke (SHS) in these locations, since 2008 postlegislation surveys in Wales., Setting: State-maintained primary schools in Wales (n=75)., Participants: Children aged 10-11 years (year 6) completed CHETS (CHild exposure to Environmental Tobacco Smoke) Wales surveys in 2007 (n=1612) and 2008 (n=1605). A replication survey (CHETS Wales 2) was conducted in 2014, including 1601 children., Primary Outcome Variable: Children's reports of whether smoking was allowed in their car or home and exposure to SHS in a car or home the previous day., Results: The percentage of children who reported that smoking was allowed in their family vehicle fell from 18% to 9% in 2014 (OR=0.42; 95% CI 0.33 to 0.54). The percentage living in homes where smoking was allowed decreased from 37% to 26% (OR=0.30; 95% CI 0.20 to 0.43). Among children with a parent who smoked, one in five and one in two continued to report that smoking was allowed in their car and home. The percentage reporting SHS exposure in a car (OR=0.52; 95% CI 0.38 to 0.72) or home (OR=0.44; 95% CI 0.36 to 0.53) the previous day also fell. Children from poorer families remained less likely to report smoking restrictions., Conclusions: Smoking in cars and homes has continued to decline. Substantial numbers of children continue to report that smoking is allowed in cars and homes, particularly children from poorer families. A growing number of countries have legislated, or plan to legislate, banning smoking in cars carrying children. Attention is needed to the impact of legislation on child health and health inequalities, and reducing smoking in homes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: While an increasing number of randomised controlled trials report impacts of exercise referral schemes (ERS) on physical activity, few have investigated the mechanisms through which increases in physical activity are produced. This study examines whether a National Exercise Referral Scheme (NERS) in Wales is associated with improvements in autonomous motivation, self-efficacy and social support, and whether change in physical activity is mediated by change in these psychosocial processes., Methods: A pragmatic randomised controlled trial of NERS across 12 LHBs in Wales. Questionnaires measured demographic data and physical activity at baseline. Participants (N = 2160) with depression, anxiety or CHD risk factors were referred by health professionals and randomly assigned to control or intervention. At six months psychological process measures were collected by questionnaire. At 12 months physical activity was assessed by 7 Day PAR telephone interview. Regressions tested intervention effects on psychosocial variables, physical activity before and after adjusting for mediators and socio demographic patterning., Results: Significant intervention effects were found for autonomous motivation and social support for exercise at 6 months. No intervention effect was observed for self-efficacy. The data are consistent with a hypothesis of partial mediation of the intervention effect by autonomous motivation. Analysis of moderators showed significant improvements in relative autonomy in all subgroups. The greatest improvements in autonomous motivation were observed among patients who were least active at baseline., Discussion: The present study offered key insights into psychosocial processes of change in an exercise referral scheme, with effects on physical activity mediated by autonomous motivation. Findings support the use of self-determination theory as a framework for ERS. Further research is required to explain socio-demographic patterning in responses to ERS, with changes in motivation occurring among all sub-groups of participants, though not always leading to higher adherence or behavioural change. This highlights the importance of socio-ecological approaches to developing and evaluating behaviour change interventions, which consider factors beyond the individual, including conditions in which improved motivation does or does not produce behavioural change., Trial Register Number: ISRCTN47680448.

Aims: This exploratory trial examines the feasibility of implementing a social norms marketing campaign to reduce student drinking in universities in Wales, and evaluating it using cluster randomised trial methodology., Methods: Fifty residence halls in 4 universities in Wales were randomly assigned to intervention or control arms. Web and paper surveys were distributed to students within these halls (n = 3800), assessing exposure/contamination, recall of and evaluative responses to intervention messages, perceived drinking norms and personal drinking behaviour. Measures included the Drinking Norms Rating Form, the Daily Drinking Questionnaire and AUDIT-C., Results: A response rate of 15% (n = 554) was achieved, varying substantially between sites. Intervention posters were seen by 80% and 43% of students in intervention and control halls respectively, with most remaining materials seen by a minority in both groups. Intervention messages were rated as credible and relevant by little more than half of students, though fewer felt they would influence their behaviour, with lighter drinkers more likely to perceive messages as credible. No differences in perceived norms were observed between intervention and control groups. Students reporting having seen intervention materials reported lower descriptive and injunctive norms than those who did not., Conclusions: Attention is needed to enhancing exposure, credibility and perceived relevance of intervention messages, particularly among heavier drinkers, before definitive evaluation can be recommended. A definitive evaluation would need to consider how it would achieve sufficient response rates, whilst hall-level cluster randomisation appears subject to a significant degree of contamination., Trial Registration: ISRCTN: ISRCTN48556384.

Background: School-based breakfast provision is increasingly being seen as a means of improving educational performance and dietary behaviour amongst children. Furthermore, recognition is growing that breakfast provision offers potential as a means of addressing social inequalities in these outcomes. At present however, the evidence base on the effectiveness of breakfast provision in bringing about these improvements is limited., Methods/design: This paper describes the research design of a large scale evaluation of the effectiveness of the Welsh Assembly Government's Primary School Free Breakfast Initiative. A cluster randomised trial, with school as the unit of randomisation was used for the outcome evaluation, with a nested qualitative process evaluation. Quantitative outcome measures included dietary habits, attitudes, cognitive function, classroom behaviour, and school attendance. The study recruited 111 primary schools in Wales, of which 56 were randomly assigned to control condition and 55 to intervention. Participants were Year 5 and 6 students (aged 9-11 years) in these schools. Data were collected for all 111 schools at each of three time points: baseline, 4 month and 12 month follow-up. This was achieved through a repeated cross-sectional survey of approximately 4350 students on each of these occasions. Of those students in Year 5 at baseline, 1975 provided data at one or both of the follow-ups, forming a nested cohort. The evaluation also included a nested process evaluation, using questionnaires, semi-structured interviews and case studies with students, school staff, and local authority scheme coordinators as key informants., Discussion: An overview of the methods used for the evaluation is presented, providing an example of the feasibility of conducting robust evaluations of policy initiatives using a randomised trial design with nested process evaluation. Details are provided of response rates and the flow of participants. Reflection is offered on methodological issues encountered at various stages through the course of the study, focusing upon issues associated with conducting a randomised trial of a government policy initiative, and with conducting research in school settings.